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Introduction Ultrasound of the lung and quantification of B lines was recently introduced as a novel tool to detect overhydration. In the present study, we aimed to evaluate a four-region protocol of lung ultrasound to determine the pulmonary fluid status in ventilated patients in the intensive care unit. Methods Fifty patients underwent both lung ultrasound and transpulmonary thermodilution measurement with the PiCCO system. An ultrasound score based on number of single and confluent B lines per intercostal space was used to quantify pulmonary overhydration. To check for reproducibility, two different intensivists who were blinded as to the ultrasound pictures reassessed and classified them using the same scoring system. The results were compared with those obtained using other methods of evaluating hydration status, including extravascular lung water index (EVLWI) and intrathoracic blood volume index calculated with data from transpulmonary thermodilution measurements. Moreover, chest radiographs were assessed regarding signs of pulmonary overhydration and categorized based on a numeric rating scale. Results Lung water assessment by ultrasound using a simplified protocol showed excellent correlation with EVLWI over a broad range of lung hydration grades and ventilator settings. Correlation of chest radiography and EVLWI was less accurate. No correlation whatsoever was found with central venous pressure measurement. Conclusion Lung ultrasound is a useful, non-invasive tool in predicting hydration status in mechanically ventilated patients. The four-region protocol that we used is time-saving, correlates well with transpulmonary thermodilution measurements and performs markedly better than chest radiography.

This study aims to assess the effectiveness of digital multidisciplinary conferences (MDCs) in preventing imaging-related quality management (QM) events during the coronavirus-disease-19 (COVID-19) pandemic. COVID-19 challenged interdisciplinary exchange and QM measures for patient safety. Regular MDCs between radiologists and intensive care unit (ICU) physicians, introduced in our hospital in 2018, enable re-evaluation of imaging examinations and bilateral feedback. MDC protocols from 2020 to 2021 were analysed regarding imaging-related QM events. Epidemiological data on COVID-19 were matched with MDCs. 333 MDCs including 1324 radiological examinations in 857 patients (median age = 64 (IQR = 55–73) years, 66.7% male) were analysed. MDCs were held within a median of 1 day after imaging (IQR = 1–3). QM events were identified in 2.7% ( n  = 36/1324) of examinations. This represented a significant decrease compared to a control group from 2018/2019 (QM events identified in 14.0%, p  < 0.001). QM incidence remained consistent in the pandemic cohort (regression coefficient estimate = -0.01, 95% confidence interval = [0.000, 0.000], p  = 0.68). 81% ( n  = 29/36) of QM events were report-related, 19% process-related ( n  = 6/36), and 2.8% indication-related ( n  = 1/36). In 7.3% ( n  = 97/1324) of examinations, the patient was affected by COVID-19. With MDCs as an effective feedback mechanism in place, the challenges of the COVID-19 pandemic led to no increase in QM incidence. Notably, COVID status did not impact QM event occurrence.

To establish a deep learning model for the detection of hypoxic-ischemic encephalopathy (HIE) features on CT scans and to compare various networks to determine the best input data format. 168 head CT scans of patients after cardiac arrest were retrospectively identified and classified into two categories: 88 (52.4%) with radiological evidence of severe HIE and 80 (47.6%) without signs of HIE. These images were randomly divided into a training and a test set, and five deep learning models based on based on Densely Connected Convolutional Networks (DenseNet121) were trained and validated using different image input formats (2D and 3D images). All optimized stacked 2D and 3D networks could detect signs of HIE. The networks based on the data as 2D image data stacks provided the best results ( AUC: 94%, ACC: 79%, AUC: 93%, ACC: 79%). We provide visual explainability data for the decision making of our AI model using Gradient-weighted Class Activation Mapping. Our proof-of-concept deep learning model can accurately identify signs of HIE on CT images. Comparing different 2D- and 3D-based approaches, most promising results were achieved by 2D image stack models. After further clinical validation, a deep learning model of HIE detection based on CT images could be implemented in clinical routine and thus aid clinicians in characterizing imaging data and predicting outcome.

Background The aim of this study was to explore the performance and outcomes for intravascular (IC) versus surface cooling devices (SFC) for targeted temperature management (TTM) after out-of-hospital cardiac arrest. Methods A retrospective analysis of data from the Time-differentiated Therapeutic Hypothermia (TTH48) trial (NCT01689077), which compared whether TTM at 33 °C for 48 h results in better neurologic outcomes compared with standard 24-h duration. Devices were assessed for the speed of cooling and rewarming rates. Precision was assessed by measuring temperature variability (TV), i.e., the standard deviation (SD) of all temperature measurements in the cooling phase. Main outcomes were overall mortality and poor neurological outcome, including death, severe disability, or vegetative status. Results A total of 352 patients had available data and were included in the analysis; of those, 218 (62%) were managed with IC. A total of 114/218 (53%) patients with IC and 61/134 (43%) with SFC were cooled for 48 h ( p  = 0.22). Time to target temperature (≤ 34 °C) was significantly shorter for patients treated with endovascular devices (2.2 [1.1–4.0] vs. 4.2 [2.7–6.0] h, p  < 0.001), but temperature was also lower on admission (35.0 [34.2–35.6] vs. 35.3 [34.5–35.8]°C; p  = 0.02) and cooling rate was similar (0.4 [0.2–0.8] vs. 0.4 [0.2–0.6]°C/h; p  = 0.14) when compared to SFC. Temperature variability was significantly lower in the endovascular device group when compared with SFC methods (0.6 [0.4–0.9] vs. 0.7 [0.5–1.0]°C; p  = 0.007), as was rewarming rate (0.31 [0.22–0.44] vs. 0.37 [0.29–0.49]°C/hour; p  = 0.02). There was no statistically significant difference in mortality (endovascular 65/218, 29% vs. others 43/134, 32%; p  = 0.72) or poor neurological outcome (endovascular 69/218, 32% vs. others 51/134, 38%; p  = 0.24) between type of devices. Conclusions Endovascular cooling devices were more precise than SFC methods in patients cooled at 33 °C after out-of-hospital cardiac arrest. Main outcomes were similar with regard to the cooling methods.

IntroductionHypernatraemia, defined as a plasma sodium concentration >145 mmol/L, is a frequent complication in critically ill patients treated in the intensive care unit (ICU) (= ICU-acquired hypernatraemia), with reported prevalence ranging from 4% to 26%. Hypernatraemia adversely affects various physiological functions and is associated with delirium, prolonged length of stay and increased ICU and post-discharge mortality. The sodium load from intravenous drug diluents significantly contributes to ICU-acquired hypernatraemia, with drug infusions comprising about 30% of the daily fluid volume of an average ICU patient. This study aims to investigate if using glucose 5% solution as the default drug diluent, instead of sodium chloride 0.9%, can reduce the prevalence of ICU-acquired hypernatraemia and improve patient outcomes.Methods and analysisTo test the effectiveness of glucose 5% solution as the default drug diluent, we will conduct a multicentre, pragmatic, embedded, open-label, stepped-wedge, cluster-randomised trial. The study will include twelve clusters (ICUs and one intermediate care unit) across six hospitals in Germany, with a projected total sample size of 4485 patients. In line with the stepped-wedge cluster-randomised design, one ICU will transition every 4 weeks, in a randomised sequence, from using sodium chloride 0.9% as the default drug diluent to glucose 5%.The primary endpoint is the prevalence of hypernatraemia >150 mmol/L through day 28. The number of days alive and free of the ICU through day 28 will be tested hierarchically as a key secondary endpoint. Other exploratory endpoints include ICU mortality, ICU-free days, hospital-free days and other clinical outcomes. The primary endpoint will be analysed using a logistic mixed-effects model.Ethics and disseminationThe trial was approved by the Charité—Universitätsmedizin Berlin Ethics Board and by the ethics board of each enrolled hospital. The results will be submitted for publication in a peer-reviewed journal and presented at one or more scientific conferences.Trial registration numberThe trial protocol was registered with the German Clinical Trials Register on 21 June 2024 prior to initiation of patient enrolment (DRKS00033397).

BackgroundStrategies to identify imaging-related error and minimise its consequences are important in the management of critically ill patients. A new quality management (QM) initiative for radiological examinations has been implemented in an intensive care unit (ICU) setting. In regular multidisciplinary conferences (MDCs), radiologists and ICU physicians re-evaluate recent examinations. Structured bilateral feedback is provided to identify errors early. This study aims at investigating its impact on the occurrence of QM events (imaging-related errors). Standardised protocols of all MDCs from 1st of June 2018 through 31st of December 2019 were analysed with regard to categories of QM events (i.e. indication, procedure, report) and resulting consequences. ResultsWe analysed 241 MDCs with a total of 973 examinations. 14.0% (n = 136/973) of examinations were affected by QM events. The majority of events were report-related (76.3%, n = 106/139, e.g. misinterpreted finding), followed by procedure-related (18.0%, n = 25/139, e.g. technical issue) and indication-related events (5.8%, n = 8/139, e.g. faulty indication). The median time until identification of a QM event (time to MDC) was 2 days (interquartile range = 2). Comparing the first to the second half of the intervention period, the incidence of QM events decreased significantly from 22.9% (n = 109/476) to 6.0% (n = 30/497) (p < 0.0001). Significance of this effect was confirmed by linear regression (p < 0.0001). ConclusionsEstablishing structured discussion and feedback between radiologists and intensive care physicians in the form of MDCs is associated with a statistically significant reduction in QM events. These results indicate that MDCs may be one suitable approach to timely identify imaging-related error.

This study investigates the association between the mean arterial blood pressure (MAP), vasopressor requirement, and severity of hypoxic-ischemic encephalopathy (HIE) after cardiac arrest (CA). Between 2008 and 2017, we retrospectively analyzed the MAP 200 h after CA and quantified the vasopressor requirements using the cumulative vasopressor index (CVI). Through a postmortem brain autopsy in non-survivors, the severity of the HIE was histopathologically dichotomized into no/mild and severe HIE. In survivors, we dichotomized the severity of HIE into no/mild cerebral performance category (CPC) 1 and severe HIE (CPC 4). We investigated the regain of consciousness, causes of death, and 5-day survival as hemodynamic confounders. Among the 350 non-survivors, 117 had histopathologically severe HIE while 233 had no/mild HIE, without differences observed in the MAP (73.1 vs. 72.0 mmHg, = 0.639). Compared to the non-survivors, 211 patients with CPC 1 and 57 patients with CPC 4 had higher MAP values that showed significant, but clinically non-relevant, MAP differences (81.2 vs. 82.3 mmHg, < 0.001). The no/mild HIE non-survivors (  = 54), who regained consciousness before death, had higher MAP values compared to those with no/mild HIE (  = 179), who remained persistently comatose (74.7 vs. 69.3 mmHg, < 0.001). The no/mild HIE non-survivors, who regained consciousness, required fewer vasopressors (CVI 2.1 vs. 3.6, < 0.001). Independent of the severity of HIE, the survivors were weaned faster from vasopressors (CVI 1.0). Although a higher MAP was associated with survival in CA patients treated with a vasopressor-supported MAP target above 65 mmHg, the severity of HIE was not. Awakening from coma was associated with less vasopressor requirements. Our results provide no evidence for a MAP target above the current guideline recommendations that can decrease the severity of HIE.

Since patients with phenylketonuria (PKU) have to follow a lifelong restriction of natural protein to lower phenylalanine-intake, they never eat fish. This diet may lead to a chronic deficit of omega-3 and omega-6 fatty acids with the risk of early atherosclerotic changes. The aim of the study was to analyse the fatty acid profile of PKU patients and to correlate the results with surrogate markers of early atherosclerotic changes [enhanced carotid intima media thickness (CIMT) and ß-stiffness index] and platelet activation. In 43 PKU patients and in 58 healthy controls we prospectively examined the fatty acid profile, CIMT, ß-stiffness index and platelet activation (flow cytometric determination of markers of platelet activation). CIMT was measured bilaterally by ultrasound. CIMTmean was defined as the mean value of the sum of CIMTleft and CIMTright. Despite of lower HDL-cholesterol and higher triglyceride concentrations in the PKU group, there was no significant difference in the omega-6 or omega-3 fatty acid profile, CIMT, ß-stiffness index between both groups. Platelet activation was not enhanced in the PKU group. Fish-free diet does not induce early atherosclerotic changes or enhanced platelet activation in PKU patients.

Objective Optimal management of out of hospital circulatory arrest (OHCA) remains challenging, in particular in patients who do not develop rapid return of spontaneous circulation (ROSC). Extracorporeal cardiopulmonary resuscitation (eCPR) can be a life-saving bridging procedure. However its requirements and feasibility of implementation in patients with OHCA, appropriate inclusion criteria and achievable outcomes remain poorly defined. Design Prospective cohort study. Setting Tertiary referral university hospital center. Patients Here we report on characteristics, course and outcomes on the first consecutive 254 patients admitted between August 2014 and December 2017. Intervention eCPR program for OHCA. Mesurements and main results A structured clinical pathway was designed and implemented as 24/7 eCPR service at the Charité in Berlin. In total, 254 patients were transferred with ongoing CPR, including automated chest compression, of which 30 showed or developed ROSC after admission. Following hospital admission predefined in- and exclusion criteria for eCPR were checked; in the remaining 224, 126 were considered as eligible for eCPR. State of the art postresuscitation therapy was applied and prognostication of neurological outcome was performed according to a standardized protocol. Eighteen patients survived, with a good neurological outcome (cerebral performance category (CPC) 1 or 2) in 15 patients. Compared to non-survivors survivors had significantly shorter time between collaps and start of eCPR (58 min (IQR 12–85) vs. 90 min (IQR 74–114), p  = 0.01), lower lactate levels on admission (95 mg/dL (IQR 44–130) vs. 143 mg/dL (IQR 111–178), p  <  0.05), and less severe acidosis on admission (pH 7.2 (IQR 7.15–7.4) vs. 7.0 (IQR6.9–7.2), p  <  0.05). Binary logistic regression analysis identified latency to eCPR and low pH as independent predictors for mortality. Conclusion An eCPR program can be life-saving for a subset of individuals with refractory circulatory arrest, with time to initiation of eCPR being a main determinant of survival.