Delirium is a frequent complication in hospitalised patients, associated with long-term cognitive impairment, prolonged hospital stays, and increased mortality. Early risk assessment is essential for implementing preventive strategies. The Mayo Delirium Prediction (MDP) tool, developed using data from a large academic hospital in the United States, includes separate models for medical and surgical patients. The MDP is available in its original and recalibrated versions. However, its performance in non-US population remains unknown. The objective of this study is to externally validate the MDP tool in a cohort of hospitalised patients from a Swiss private hospital. This retrospective validation study used routinely collected clinical data from adult medical and surgical inpatients admitted to a Swiss hospital in May and June 2023. Delirium diagnosis was based on the Delirium Observation Screening Scale (DOSS). Predictive performance was assessed using the Area Under the Receiver Operating Characteristic curve (AUROC) and calibration plots. Additional sensitivity analyses were performed to assess the model’s robustness and mitigate possible biases in the evaluation. The original medical MDP tool achieved the best predictive performance in the external validation cohort of 947 patients, with an AUROC of 0·87 (95

Objectives Postoperative delirium (POD) is a common complication in surgical patients over 60, increasing morbidity, mortality and hospital stays. While international guidelines recommend risk screening, resource constraints limit implementation. This study externally validated the Pre-Interventional Preventive Risk Assessment (PIPRA) algorithm, a CE-certified tool for identifying high-risk patients to enable targeted prevention.Methods A prospective validation study was conducted at a 335-bed Swiss hospital as part of a quality improvement initiative. Data from 866 patients aged ≥60 undergoing non-cardiac, non-intracranial surgery (May–June 2023) were analysed. The PIPRA model’s performance was assessed on discrimination (Area Under the Receiver Operating Characteristic Curve (AUROC)) and calibration.Results POD occurred in 11.5% (n=100) of patients. The PIPRA model showed good discrimination (AUROC=0.77, 95% CI: 0.72 to 0.82) and generally accurate calibration, though slightly overpredicting risk in high-risk patients. POD was associated with higher mortality, prolonged intensive care unit (ICU)/hospital stays and increased nursing care needs. The model effectively stratified patients for targeted interventions.Discussion The PIPRA algorithm demonstrated robust performance in a real-world setting, affirming its utility for POD risk prediction. The study highlighted the model’s applicability across diverse clinical environments, despite differences in patient populations and screening protocols.Conclusions The PIPRA algorithm is a reliable tool for identifying surgical patients at risk of POD, supporting early intervention strategies to improve patient outcomes. Its integration into clinical workflows may enhance POD prevention efforts and optimise resource allocation in perioperative care.

BACKGROUND:Postoperative delirium (POD) arises among older surgical patients. Screening followed by prevention efforts are recommended. A risk prediction tool called PIPRA plus has been developed, yet its performance and whether adoption into health services is cost-effective are unknown. OBJECTIVE:To estimate the expected change to 'total costs' and 'health benefits' measured by quality adjusted life years (QALYs) from a decision to adopt PIPRA plus for screening purpose to find at-risk individuals who are then offered nonpharmacological interventions to reduce risks of POD. DESIGN:Cost-effectiveness modelling study that draws on a range of relevant data sources. SETTING:Swiss healthcare system. SUBJECTS:Surgical inpatients aged 60 or older, excluding cardiac and intracranial surgeries. METHODS:A decision tree model was used to capture the events likely to impact on cost and health outcomes. Information was harvested from a prospective before-after study done in Switzerland and augmented with other data. Probabilistic sensitivity analysis was undertaken to reveal the probability that adoption was cost-effective against a stated maximum willingness to pay threshold for decision-making in Switzerland. RESULTS:Patients in both phases of the study were similar. Costs were lower by 2898 CHF (SD 1050) per patient with the adoption of the risk screening tool and there was a modest gain to health benefits of 0.01 QALY (SD 0.026). There was a 99.7% probability that adoption would be cost-saving and 91% probability that adoption would be cost-effective. CONCLUSIONS:We provide early-stage evidence that a decision to adopt the risk screening tool and offer risk-reducing interventions could be cost-effective.

BACKGROUND:Postoperative delirium (POD) significantly impacts older surgical patients, necessitating effective prevention strategies. OBJECTIVE:To assess the effectiveness of the Pre-Interventional Preventive Risk Assessment (PIPRA) automated delirium risk prediction tool alongside non-pharmacological prevention strategies on POD incidence, hospital length of stay (LOS) and nursing time. METHODS:This quality improvement project, set in a 335-bed Swiss private hospital, employed a before-after design to evaluate the impact of PIPRA and preventive measures on POD, LOS and nursing time in non-cardiac and non-intracranial surgery inpatients aged 60 or older. The control phase focused on enhancing POD screening, whilst the intervention phase incorporated PIPRA for risk assessment and staff training to enable targeted non-pharmacological prevention in patients at risk. RESULTS:A total of 866 patients were included; 299 control and 567 intervention. The odds ratio of POD, comparing the intervention group to the control, was 0.71 [95% confidence interval (CI) 0.44-1.16] when adjusting for baseline patient characteristics. The intervention was associated with an LOS 0.94 (95% CI 0.85-1.05) and nursing time 0.96 (95% CI 0.86-1.07) times that of the control, adjusted for baseline patient characteristics. Medium risk patients (21.6% of patients) had an LOS 0.74 (95% CI 0.59-0.92) and required nursing time 0.79 (95% CI from 0.62-1.00) times the control, adjusted for baseline patient characteristics, equivalent to an LOS reduction of 1.36 days and nursing time saving of 19.3 hours per patient. CONCLUSIONS:Medium risk patients in the intervention group had shorter LOS and nursing time compared to the control group, underscoring the importance of targeted prevention.

Moderate to severe traumatic brain injuries (TBI) require treatment in an intensive care unit (ICU) in close collaboration of a multidisciplinary team consisting of different medical specialists such as intensivists, neurosurgeons, neurologists, as well as ICU nurses, physiotherapists, and ergo-/logotherapists. Major goals include all measurements to prevent secondary brain injury due to secondary brain insults and to optimize frame conditions for recovery and early rehabilitation. The distinction between moderate and severe is frequently done based on the Glascow Coma Scale and therefore often is just a snapshot at the early time of assessment. Due to its pathophysiological pathways, an initially as moderate classified TBI may need the same sophisticated surveillance, monitoring, and treatment as a severe form or might even progress to a severe and difficult to treat affection. As traumatic brain injury is rather a syndrome comprising a range of different affections to the brain and as, e.g., age-related comorbidities and treatments additionally may have a great impact, individual and tailored treatment approaches based on monitoring and findings in imaging and respecting pre-injury comorbidities and their therapies are warranted.

Institute for Anesthesia and Intensive Care Medicine, Hirslanden Institute for Medical Education, Klinik Hirslanden, Zurich, Switzerland *See also p. 2010. Dr. Stocker has disclosed that he does not have any potential conflicts of interest.

Zusammenfassung. Die aktuellen und zukünftigen (ethischen) Herausforderungen in der Intensivmedizin werden stark durch die aktuellen Entwicklungen in der Demographie und in der digitalen Welt beeinflusst. Ersteres wird Herausforderungen verschärfen, die bereits heute bestehen. Die digitale Transformation wird zur wahrscheinlich fundamentalsten Veränderung führen, die die moderne Medizin je gesehen hat. Nebst der personalisierten Medizin wird das Medizinalpersonal gefordert, sich über das Wissen und Können hinaus wieder vermehrt mit der Medizin als Kunst zu befassen und der Interaktion mit dem Patienten bzw. auch seinen Angehörigen ein hohes Gewicht beizumessen.

Institute for Anesthesiology and Intensive Care Medicine Clinic Hirslanden, CH-8032 Zurich, Switzerland *See also p. 2163. Dr. Stocker served as a board member for the Advisory Board on Fluid Resuscitation and lectured for several lectures on fluid resuscitation. His institution received funding from Unrestricted Grant for PI driven Research in Fluid Resuscitation by Fresenius-Kabi.

BACKGROUND:Underreporting of intraoperative events in anaesthesia is well-known and compromises quality documentation. The reasons for such omissions remain unclear. We conducted a questionnaire-based survey of anaesthesia staff to explore perceived barriers to reliable documentation during anaesthesia.METHODS:Participants anonymously completed a paper-based questionnaire. Predefined answers referred to potential barriers. Additional written comments were encouraged. Differences between physician and nurse anaesthetists were tested with t-tests and chi-square tests.RESULTS:Twenty-five physician and 30 nurse anaesthetists (81% of total staff) completed the survey. The reported problems referred to three main categories: (I) potential influences related to working conditions and practices of data collection, such as premature entry of the data (indicated by 85% of the respondents), competing duties (87%), and interfering interruptions or noise (67%); (II) problems referring to institutional management of the data, for example lacking feedback on the results (95%) and lacking knowledge about what the data are used for (75%); (III) problems related to specific attitudes, e.g., considering these data not useful for quality improvement (47%). Physicians were more sceptical than nurses regarding the relevance of these data for quality and patient safety.CONCLUSIONS:The common perceived difficulties reported by physician and nurse anaesthetists resemble established barriers to incident reporting and may similarly act as barriers to quality documentation during anaesthesia. Further studies should investigate if these perceived obstacles have a causal impact on quality reporting in anaesthesia.TRIAL REGISTRATION:ClinicalTrials.gov identifier is NCT01524484. Registration date: January 21, 2012.

INTRODUCTION:Regional citrate anticoagulation (RCA) for continuous renal replacement therapy is widely used in intensive care units (ICUs). However, concern exists about the safety of citrate in patients with liver failure (LF). The aim of this study was to evaluate safety and efficacy of RCA in ICU patients with varying degrees of impaired liver function.METHODS:In a multicenter, prospective, observational study, 133 patients who were treated with RCA and continuous venovenous hemodialysis (RCA-CVVHD) were included. Endpoints for safety were severe acidosis or alkalosis (pH ≤7.2 or ≥7.55, respectively) and severe hypo- or hypercalcemia (ionized calcium ≤0.9 or ≥1.5 mmol/L, respectively) of any cause. The endpoint for efficacy was filter lifetime. For analysis, patients were stratified into three predefined liver function or LF groups according to their baseline serum bilirubin level (normal liver function ≤2 mg/dl, mild LF >2 to ≤7 mg/dl, severe LF >7 mg/dl).RESULTS:We included 48 patients with normal liver function, 43 with mild LF, and 42 with severe LF. LF was predominantly due to ischemia (39 %) or multiple organ dysfunction syndrome (27 %). The frequency of safety endpoints in the three patient strata did not differ: severe alkalosis (normal liver function 2 %, mild LF 0 %, severe LF 5 %; p = 0.41), severe acidosis (normal liver function 13 %, mild LF 16 %, severe LF 14 %; p = 0.95), severe hypocalcemia (normal liver function 8 %, mild LF 14 %, severe LF 12 %; p = 0.70), and severe hypercalcemia (0 % in all strata). Only three patients showed signs of impaired citrate metabolism. Overall filter patency was 49 % at 72 h. After censoring for stop of the treatment due to non-clotting causes, estimated 72-h filter survival was 96 %.CONCLUSIONS:RCA-CVVHD can be safely used in patients with LF. The technique yields excellent filter patency and thus can be recommended as first-line anticoagulation for the majority of ICU patients.TRIAL REGISTRATION:ISRCTN Registry identifier: ISRCTN92716512 . Date assigned: 4 December 2008.

There are limited data on the efficacy of early fluid resuscitation with third-generation hydroxyethyl starch (HES 130) in burn injury. Adverse effects of HES on survival and organ function have been reported.

Background. The Molecular Adsorbent Recirculating System (MARS) has been shown to clear albumin-bound toxins from patients with liver failure but might cause bleeding complications potentially obscuring survival benefits. We hypothesized that monitoring clotting parameters and bed-side thromboelastography allows to reduce bleeding complications. Methods. Retrospective analysis of 25 MARS sessions during which clotting parameters were monitored by a standardized protocol. Results. During MARS therapy median INR increased significantly from 1.7 to 1.9 platelet count and fibrinogen content decreased significantly from 57 fL−1 to 42 fL−1 and 2.1 g/L to 1.5 g/L. Nine relevant complications occurred: the MARS system clotted 6 times 3 times we observed hemorrhages. Absent thrombocytopenia and elevated plasma fibrinogen predicted clotting of the MARS system (ROC 0.94 and 0.82). Fibrinolysis, detected by thromboelastography, uniquely predicted bleeding events. Conclusion. Bed-side thromboelastography and close monitoring of coagulation parameters can predict and, therefore, help prevent bleeding complications during MARS therapy.

This study was undertaken as the first national single-center analysis to assess the impact of the new Swiss transplantation law on patient selection, intensive care unit (ICU) complications, outcome, and, in particular, costs in liver transplant recipients treated in our surgical ICU. The first 35 consecutive liver transplant recipients following the new act were compared with the last 35 liver transplant recipients preceding July 1, 2007. Following execution of the new law, recipients were in poorer condition, reflected by significant higher Model for End-Stage Liver Disease (MELD) scores (12 vs. 22; p = 0.006). Furthermore, the MELD group obtained more renal replacement therapies (40.0% vs. 14.3%; p = 0.015). Cumulative one-yr patient survival was comparable in both groups (91.4% vs. 80.1%, p = 0.22). Finally, the additional costs per single case increased 27 000 Euros after the adoption of the new law. Our data serve as an example that political decisions influence patient's selection, and, in turn, complications, finally leading to higher costs of medical treatment. Liver graft allocation according to the MELD system may save lives at the price of increased intensive care efforts.

For the last then thousands of years a symbiotic relationship between colonizing flora in the host has emerged to benefit both parties. However, modern advances in medicine allowing treatment of critically ill and compromised patients including use of potent antimicrobials forced the intestinal flora to adapt and develop strategies to survive against threats originating from a hostile environment and attempts of its extermination. Research work has shown that for this purpose microbials are able to communicate, to organize in functional communities and to regulate their virulence in order to protect their self-interests. It could be demonstrated that this germs mainly generate adverse effects against the host by interacting with his epithelial cells i.e. in the intestines. By doing so the bacteria can induce paracellular permeability defects promoting translocation of toxins with systemic downstream effects. Moreover some germs are able to corrupt and exploit host cellular function in order to satisfy their needs leading to harm to the host more as a collateral damage. In the post antibiotic aera future treatment concepts to prevent devastating effects of, gut derived sepsis" should therefore become directed towards optimization of microbial frame conditions in order to minimize their need to up-regulate virulence and thus jeopardize the host.

INTRODUCTION:The impact of model of end stage liver disease (MELD) score on postoperative morbidity and mortality is still elusive, especially for high MELD. There are reports of poorer patient outcome in transplant candidates with high MELD score, others though report no influence of MELD score on outcome and survival.METHODS:We retrospectively analyzed data of 144 consecutive liver transplant recipients over a 72-month period in our transplant unit, from January 2003 until December 2008 and performed uni- and multivariate analysis for morbidity and mortality, in particular to define the influence of MELD to these parameters.RESULTS:This study identified MELD score greater than 23 as an independent risk factor of morbidity represented by intensive care unit (ICU) stay longer than 10 days (odds ratio 7.0) but in contrast had no negative impact on mortality. Furthermore, we identified transfusion of more than 7 units of red blood cells as independent risk factor for mortality (hazard ratio 7.6) and for prolonged ICU stay (odds ratio [OR] 7.8) together with transfusion of more than 10 units of fresh frozen plasma (OR 11.6). Postoperative renal failure is a strong predictor of morbidity (OR 7.9) and postoperative renal replacement therapy was highly associated with increased mortality (hazard ratio 6.8), as was hepato renal syndrome prior to transplantation (hazard ratio 13.2).CONCLUSIONS:This study identified MELD score greater than 23 as an independent risk factor of morbidity represented by ICU stay longer than 10 days but in contrast had no negative impact on mortality. This finding supports the transplantation of patients with high MELD score but only with knowledge of increased morbidity.