Nebulized heparin in burn patients with inhalation trauma : safety and feasibility

Background: Pulmonary hypercoagulopathy is intrinsic to inhalation trauma. Nebulized heparin could theoretically be beneficial in patients with inhalation injury, but current data are conflicting. We aimed to investigate the safety, feasibility, and effectiveness of nebulized heparin. Methods: International multicenter, double-blind, placebo-controlled randomized clinical trial in specialized burn care centers. Adult patients with inhalation trauma received nebulizations of unfractionated heparin (25,000 international unit (IU), 5 mL) or placebo (0.9% NaCl, 5 mL) every four hours for 14 days or until extubation. The primary outcome was the number of ventilator-free days at day 28 post-admission. Here, we report on the secondary outcomes related to safety and feasibility. Results: The study was prematurely stopped after inclusion of 13 patients (heparin N = 7, placebo N = 6) due to low recruitment and high costs associated with the trial medication. Therefore, no analyses on effectiveness were performed. In the heparin group, serious respiratory problems occurred due to saturation of the expiratory filter following nebulizations. In total, 129 out of 427 scheduled nebulizations were withheld in the heparin group (in 3 patients) and 45 out of 299 scheduled nebulizations were withheld in the placebo group (in 2 patients). Blood-stained sputum or expected increased bleeding risks were the most frequent reasons to withhold nebulizations. Conclusion: In this prematurely stopped trial, we encountered important safety and feasibility issues related to frequent heparin nebulizations in burn patients with inhalation trauma. This should be taken into account when heparin nebulizations are considered in these patients

Soluble urokinase-type plasminogen activator receptor levels in patients with burn injuries and inhalation trauma requiring mechanical ventilation: an observational cohort study

Soluble urokinase-type plasminogen activator receptor (suPAR) has been proposed as a biologic marker of fibrinolysis and inflammation. The aim of this study was to investigate the diagnostic and prognostic value of systemic and pulmonary levels of suPAR in burn patients with inhalation trauma who need mechanical ventilation. suPAR was measured in plasma and nondirected lung-lavage fluid of mechanically ventilated burn patients with inhalation trauma. The samples were obtained on the day of inhalation trauma and on alternate days thereafter until patients were completely weaned from the mechanical ventilator. Mechanically ventilated patients without burns and without pulmonary disease served as controls. Systemic levels of suPAR in burn patients with inhalation trauma were not different from those in control patients. On admission and follow up, pulmonary levels of suPAR in patients with inhalation trauma were significantly higher compared with controls. Pulmonary levels of suPAR highly correlated with pulmonary levels of interleukin 6, a marker of inflammation, and thrombin-antithrombin complexes, markers of coagulation, but not plasminogen activator activity, a marker of fibrinolysis. Systemic levels of suPAR were predictive of the duration of mechanical ventilation and length of intensive care unit (ICU) stay. Duration of mechanical ventilation and length of ICU stay were significantly longer in burn-injury patients with systemic suPAR levels > 9.5 ng/ml. Pulmonary levels of suPAR are elevated in burn patients with inhalation trauma, and they correlate with pulmonary inflammation and coagulation. Although pulmonary levels of suPAR may have diagnostic value in burn-injury patients, systemic levels of suPAR have prognostic valu

An evaluation of the Integrated Pulmonary Index (IPI) for the detection of respiratory events in propofol sedated patients undergoing upper gastrointestinal endoscopy

Background: Monitoring of patients respiratory and ventilatory status during moderate-to-deep sedation in upper gastrointestinal (GI) endoscopic procedures may enable early recognition of altered respiratory patterns with potential danger for vital functions. The current standards of care for monitoring the ventilatory status during sedation are pulse oximetry and visual inspection of the breathing pattern. EtCO2 monitoring is not routinely used. The Integrated Pulmonary Index (IPI) monitor is developed to detect specific patient’s respiratory depression and changes status during sedation, by measuring the EtCO2, respiratory rate, SpO2 and pulse rate, displayed on a monitor. This monitor might provide an indication of the patient’s overall ventilator status. The aim of this study was to explore the validity of the IPI index during PSA procedures and its application during upper GI endoscopy treatments, compared with our traditional current standards of monitoring care. Methods: Twenty patients, scheduled for upper GI endoscopy procedures gave their informed consent. All patients were moderately to deeply sedate by trained sedation practitioners. Aside from standard monitoring, additionally the IPI was continuously measured, on a capnostream monitor. All data were analyzed and compared with the clinical status of the patient. Results: All patients were moderate-to-deep sedated for upper GI endoscopy procedures. The mean age of the patients was 56 years. In 15/100 measure points, the IPI values (lower than 7) were not in agreement with the actual clinical state of the patient. The most common discrepancies, 9/100, were associated with an overshoot of the EtCO2 value, due to leakage of CO2, insufflated through the endoscope. Conclusion: The IPI value as an early warning monitor of the ventilation in moderate-to-deep sedation procedures remains unclear and deserves further study. Its use in upper endoscopic gastrointestinal procedures where CO2 insufflation is used by the endoscopist cannot be recommended

An evaluation of the Integrated Pulmonary Index (IPI) for the detection of respiratory events in propofol sedated patients undergoing upper gastrointestinal endoscopy

Background: Monitoring of patients respiratory and ventilatory status during moderate-to-deep sedation in upper gastrointestinal (GI) endoscopic procedures may enable early recognition of altered respiratory patterns with potential danger for vital functions. The current standards of care for monitoring the ventilatory status during sedation are pulse oximetry and visual inspection of the breathing pattern. EtCO2 monitoring is not routinely used. The Integrated Pulmonary Index (IPI) monitor is developed to detect specific patient’s respiratory depression and changes status during sedation, by measuring the EtCO2, respiratory rate, SpO2 and pulse rate, displayed on a monitor. This monitor might provide an indication of the patient’s overall ventilator status. The aim of this study was to explore the validity of the IPI index during PSA procedures and its application during upper GI endoscopy treatments, compared with our traditional current standards of monitoring care. Methods: Twenty patients, scheduled for upper GI endoscopy procedures gave their informed consent. All patients were moderately to deeply sedate by trained sedation practitioners. Aside from standard monitoring, additionally the IPI was continuously measured, on a capnostream monitor. All data were analyzed and compared with the clinical status of the patient. Results: All patients were moderate-to-deep sedated for upper GI endoscopy procedures. The mean age of the patients was 56 years. In 15/100 measure points, the IPI values (lower than 7) were not in agreement with the actual clinical state of the patient. The most common discrepancies, 9/100, were associated with an overshoot of the EtCO2 value, due to leakage of CO2, insufflated through the endoscope. Conclusion: The IPI value as an early warning monitor of the ventilation in moderate-to-deep sedation procedures remains unclear and deserves further study. Its use in upper endoscopic gastrointestinal procedures where CO2 insufflation is used by the endoscopist cannot be recommended

Rhetorisch-stilistische Eigenschaften der Sprache von Religion und Kirche.

Paul I. Rhetorisch-stilistische Eigenschaften der Sprache von Religion und Kirche. In: Fix U, Gardt A, Knape J, eds. Rhetorik und Stilisitk. Ein internationales Handbuch historischer und systematischer Forschung. 2. Halbband. Berlin/New York; 2009: 2257-2274

Modeling turnover intentions, burnout, and job satisfaction of nurse anesthetists:The sensitivity of results to choice of statistical method

Turnover by nurse anesthetists is expensive because they are highly skilled and difficult to replace. This study examines the turnover intentions of 882 Dutch nurse anesthetists. Turnover intention is modeled as a function of job satisfaction, burnout, personality, work context characteristics, and work climate. Previous research used the dataset to estimate the model using structural equation modeling (SEM). This study examines the sensitivity of results by using a two-level multilevel model with fixed or random intercepts. This study finds that the major substantive conclusions of the previous study are not sensitive to statistical methodology, which increases ones confidence in the conclusions

Pulmonary activation of coagulation and inhibition of fibrinolysis after burn injuries and inhalation trauma

BACKGROUND: Pulmonary coagulopathy is intrinsic to pneumonia and other forms of acute lung injury. We hypothesized patients with burn injuries and inhalation trauma to have similar alterations in pulmonary coagulation and fibrinolysis. METHODS: We performed a prospective study on changes in pulmonary and systemic thrombin generation and fibrinolytic activity in patients with burn injuries and inhalation trauma requiring mechanical ventilation. Nondirected bronchial lavage was performed on alternate days. Patients requiring mechanical ventilation for nonpulmonary reasons who did not meet the North American European Consensus Conference criteria for acute lung injury functioned as control patients. RESULTS: We studied 13 patients with burn injuries and inhalation trauma and 15 control patients. On admission, patients with burn injuries and inhalation trauma showed a significant increase in thrombin generation in the airways compared with control patients, as reflected by increased lavage fluid levels of thrombin-antithrombin complexes and fibrin degradation products, and decreased lavage fluid levels of activated protein C and antithrombin. Simultaneously, burn patients showed a significant decrease in fibrinolytic activity, as reflected by decreased lavage fluid levels of plasminogen activator activity. Pulmonary coagulopathy persisted throughout the period of mechanical ventilation and was accompanied by similar changes in systemic coagulation and fibrinolysis. There was no significant correlation between changes in coagulation and fibrinolysis and the extent of burn injury. CONCLUSIONS: Patients with burn injuries and inhalation trauma requiring mechanical ventilation show a distinct and sustained procoagulant and antifibrinolytic shift in the pulmonary compartment. Pulmonary coagulopathy could be an important therapeutic target in these patients