Andreas Perren - Academia.edu (original) (raw)
Papers by Andreas Perren
The American Journal of Cardiology, 2007
Critically ill patients commonly show a decrease in hemoglobin concentration during their stay in... more Critically ill patients commonly show a decrease in hemoglobin concentration during their stay in the intensive care unit. The purpose of the present study was to evaluate whether nonbleeding patients with acute coronary syndrome (ACS) show a similar decrease of hemoglobin, and thereby furnish reference values and analyze possible mechanisms. In this retrospective, descriptive study, the charts of all patients with ACS hospitalized between January 2004 and September 2005 were screened with regard to patient characteristics, time course of hemoglobin, as well as clinical parameters, concomitant drug therapy, and fluid balances. One hundred three nonbleeding patients with ACS were analyzed. They showed an average hemoglobin decrease of 1.27 ؎ 1.00 g/dl (p <0.001). The decrease in hemoglobin level was observed during the first 12 to 24 hours; thereafter the hemoglobin concentration remained stable. We found a correlation among decrease of hemoglobin, parameters of stress, such as hypertension (p ؍ 0.019), tachycardia (p ؍ 0.004), pain (p ؍ 0.043), and white blood cells (p ؍ 0.021), as well as the intravenous administration of nitroglycerin (p ؍ 0.004). In conclusion, during the first 24 hours in the intensive care unit the hemoglobin concentration of nonbleeding patients with ACS regularly decreases at 1.27 ؎ 1.00 g/dl. Any further decrease in hemoglobin level beyond these values should entail early active search of the bleeding source. We hypothesize that this decrease is due to normalization of the previous stress-induced hemoconcentration and "internal hemodilution" by nitroglycerin.
[Non infectious postoperative fever]
Praxis
We present the case of a 74-years old man with subtotal gastrectomy for adenocarcinoma, whose pos... more We present the case of a 74-years old man with subtotal gastrectomy for adenocarcinoma, whose postoperative course is complicated by a prolonged fever. Despite extensive diagnostics, the origin of the postoperative fever remains unexplained for 47 days, when the patient is transferred to the ICU because of lethargy, hemodynamic instability, lung edema and abdominal symptoms. The diagnosis of Addison crisis is established and under substitution with hydrocortisone all the symptoms rapidly resolve. Postoperative fever is relatively frequent and infectious causes account for about half of the cases only. An infectious origin has imperatively to be excluded when the fever arises later than 48 hrs after surgery. In case of prolonged fever we suggest to extend the differential diagnosis to other than infectious causes by means of special lists (e.g fever of unknown origin).
A case of central alveolar hypoventilation in medullary thyroid cancer
Swiss medical weekly: official journal of the Swiss Society of Infectious Diseases, the Swiss Society of Internal Medicine, the Swiss Society of Pneumology
[ARDS in plasmodium vivax malaria]
Schweizerische medizinische Wochenschrift
Acute renal failure, disseminated intravascular coagulation, ARDS, hypoglycaemia, coma or epilept... more Acute renal failure, disseminated intravascular coagulation, ARDS, hypoglycaemia, coma or epileptic seizures are manifestations of severe Plasmodium falciparum malaria. On the other hand, vivax malaria or benign tertian malaria is usually free from complications. In the present report we describe a case of acute tertian malaria with a severe and complicated course. In this situation bacterial coinfection should always be suspected and treated empirically with broad-spectrum antibiotics, until the results of cultures are available. Mixed plasmodial infection (P. vivax and P. falciparum) must be excluded by repeated and meticulous examination of blood smears. Newer techniques such as PCR processing or ParaSight F Test are mentioned.
[Detection of hereditary hemochromatosis]
Revue médicale suisse
Hereditary hemochromatosis is one of the most common genetic disorders. The prognosis of hemochro... more Hereditary hemochromatosis is one of the most common genetic disorders. The prognosis of hemochromatosis is normal when phlebotomy therapy is started prior to manifestation of cirrhosis or diabetes. High ferritin is not always a marker of iron overload and ferritin must thus be coupled with transferrin saturation. Only high transferrin saturation entails a genetic research (HFE or type 1). The identification of rare types of hemochromatosis (types 2-4) is only required in particular cases. The evaluation of the iron overload is now based on hepatic MRI determination rather than liver biopsy.
Physical restraint in the ICU - does it prevent device removal? A critical appraisal
Minerva anestesiologica, Jan 12, 2014
Physical restraint is frequently used in the intensive care setting but little is known regarding... more Physical restraint is frequently used in the intensive care setting but little is known regarding its clinical scenario and effectiveness in preventing adverse events (AEs), defined as device removal. A prospective observational study in three Intensive Care Units on 120 adult high--risk patients. The effectiveness of physical restraint was evaluated using the propensity score methodology in order to obtain comparable groups. Physical restraint was applied in 1371 of 3256 (43%) nurse shifts accounting for 120 patients. Substantial agitation, the nurse&amp;#39;s judgement of insufficient sedation and sedative drug reduction were positively associated with physical restraint, whereas the presence of analgesics at admission, increased disease gravity and the treating hospital as the most substantial variable showed a negative association. Eighty--six AEs were observed in 44 patients. Quiet (SAS=1--4), unrestrained patients accounted for 40 cases, and agitated (SAS≥5) but physically restrained patients for 17 cases. The presence of any type of physical restraint had a protective effect against any type of AE (OR=0.28; CI 0.16-0.51). The observed AEs showed a limited impact on the patients&amp;#39; course of illness. No physical harm related to physical restraint was reported. Physical restraint efficiently averts AEs. Its application is mainly driven by local habits. Typically, the almost recovered, apparently calm and hence unrestrained patient is at greatest risk for undesirable device removal. The control/interpretation of the patient&amp;#39;s analgo--sedation might be inappropriate.
[Latin organ donation programme (LODP): an effective initiative to increase organ donation in Switzerland]
Revue médicale suisse, Jan 22, 2011
The 1st federal transplant law was enforced in July 2007 with the obligation to promote quality a... more The 1st federal transplant law was enforced in July 2007 with the obligation to promote quality and efficiency in the procedures for organ and tissue donation for transplantation. The Latin organ donation programme (LODP) created in 2008 aims to develop organ donation in 17 public hospitals in 7 Latin cantons, covering 2.2 million people; 29% of the Swiss population. The implementation of various effective measures by the LODP enabled the increase in the number of donors by 70% between 2008 and 2010, with four organs procured per donor; greatly exceeding the European average of three. The results show that LODP has successfully professionalised the system and we can only hope that similar organisations will be put into place throughout Switzerland.
Fluid balance in critically ill patients. Should we really rely on it?
Minerva anestesiologica, 2011
The computation of fluid balances (FBs) by subtracting fluid outputs from inputs is a common crit... more The computation of fluid balances (FBs) by subtracting fluid outputs from inputs is a common critical care practice. Limited information exists about the accuracy and consistency of nurse-registered cumulative FBs and regarding the value of suggested corrections for non-measurable losses. From 147 ICU patients, we prospectively evaluated the cumulative FBs and their relationship to changes in body weight (BW). Standardised measurements of BW were performed on admission and discharge. FB charts were accurately reviewed and arithmetic errors corrected. Net cumulative FBs and adjusted cumulative FBs (considering sensible or insensible fluid losses/fever/liquid faeces) were analysed for all patients and 3 subgroups (cardiac-cerebral, septic, and others). Agreement between FBs and BW changes was calculated according to the defined subgroups and confounding variables. Cumulative FBs were inaccurate in 49 cases (33%) with errors ranging from -3606 mL to +2020 mL. The total (average daily) ...
[Adverse internal medicine drug effects at hospital admission]
Schweizerische medizinische Wochenschrift, Jan 19, 1999
Hospital admissions due to adverse drug reactions are an important concern, but there are few dat... more Hospital admissions due to adverse drug reactions are an important concern, but there are few data concerning the specific situation in Switzerland. During one year we therefore prospectively studied all admissions to our medical department to determine the profile. 138 of 2168 patients presented a total of 150 adverse drug reactions at hospitalisation (6.4%) and among them 65% of the admissions were directly related to adverse drug reaction. Age stratification revealed that with each decade of age there was an increasing risk of adverse drug reactions and that the patients were sicker (more diagnoses), were consuming more drugs and had longer stays. The majority of adverse drug reactions were type A reactions and therefore potentially preventable. Cardio- and cerebrovascular drugs (diuretics, ACE-inhibitors, platelet aggregation inhibiting therapy) accounted for 65% of the side effects. Analysed by affected organ system, the most frequent adverse drug reactions were gastrointestina...
Postoperatives Fieber – nicht immer infektiöser Art
Praxis, 2007
Swiss medical weekly, 2014
The first description of the simplified acute physiology score (SAPS) II dates back to 1993, but ... more The first description of the simplified acute physiology score (SAPS) II dates back to 1993, but little is known about its accuracy in daily practice. Our purpose was to evaluate the accuracy of scoring and the factors that affect it in a nationwide survey. Twenty clinical scenarios, covering a broad range of illness severities, were randomly assigned to a convenience sample of physicians or nurses in Swiss adult intensive care units (ICUs), who were asked to assess the SAPS II score for a single scenario. These data were compared to a reference that was defined by five experienced researchers. The results were cross-matched with demographic characteristics and data on the training and quality control for the scoring, structural and organisational properties of each participating ICU. A total of 345 caregivers from 53 adult ICU providers completed the SAPS II evaluation of one clinical scenario. The mean SAPS II scoring was 42.6 ± 23.4, with a bias of +5.74 (95%CI 2.0-9.5) compared ...
The Difficulty of Measuring the Measurable
Respiratory Care, 2014
Critical Care Research and Practice, 2012
Background. Reliable ICU severity scores have been achieved by various healthcare workers but not... more Background. Reliable ICU severity scores have been achieved by various healthcare workers but nothing is known regarding the accuracy in real life of severity scores registered by untrained nurses. Methods. In this retrospective multicentre audit, three reviewers independently reassessed 120 SAPS II scores. Correlation and agreement of the sum-scores/variables among reviewers and between nurses and the reviewers' gold standard were assessed globally and for tertiles. Bland and Altman (gold standardnurses) of sum scores and regression of the difference were determined. A logistic regression model identifying risk factors for erroneous assessments was calculated. Results. Correlation for sum scores among reviewers was almost perfect (mean ICC = 0.985). The mean (±SD) nurse-registered SAPS II sum score was 40.3 ± 20.2 versus 44.2 ± 24.9 of the gold standard (P < 0.002 for difference) with a lower ICC (0.81). Bland and Altman assay was +3.8 ± 27.0 with a significant regression between the difference and the gold standard, indicating overall an overestimation (underestimation) of lower (higher; >32 points) scores. The lowest agreement was found in high SAPS II tertiles for haemodynamics (k = 0.45-0.51). Conclusions. In real life, nurse-registered SAPS II scores of very ill patients are inaccurate. Accuracy of scores was not associated with nurses' characteristics.
Annals of Intensive Care, 2012
Background: Adverse events (AEs) frequently occur in intensive care units (ICUs) and affect negat... more Background: Adverse events (AEs) frequently occur in intensive care units (ICUs) and affect negatively patient outcomes. Targeted improvement strategies for patient safety are difficult to evaluate because of the intrinsic limitations of reporting crude AE rates. Single interventions influence positively the quality of care, but a multifaceted approach has been tested only in selected cases. The present study was designed to evaluate the rate, types, and contributing factors of emerging AEs and test the hypothesis that a multifaceted intervention on medication might reduce drug-related AEs. Methods: This is a prospective, multicenter, before-and-after study of adult patients admitted to four ICUs during a 24-month period. Voluntary, anonymous, self-reporting of AEs was performed using a detailed, locally designed questionnaire. The temporal impact of a multifaceted implementation strategy to reduce drug-related AEs was evaluated using the risk-index scores methodology. Results: A total of 2,047 AEs were reported (32 events per 100 ICU patient admissions and 117.4 events per 1,000 ICU patient days) from 6,404 patients, totaling 17,434 patient days. Nurses submitted the majority of questionnaires (n = 1,781, 87%). AEs were eye-witnessed in 49% (n = 1,003) of cases and occurred preferentially during an elective procedure (n = 1,597, 78%) and on morning shifts (n = 1,003, 49%), with a peak rate occurring around 10 a.m. Drug-related AEs were the most prevalent (n = 984, 48%), mainly as a consequence of incorrect prescriptions. Poor communication among caregivers (n = 776) and noncompliance with internal guidelines (n = 525) were the most prevalent contributing factors for AE occurrence. The majority of AEs (n = 1155, 56.4%) was associated with minimal, temporary harm. Risk-index scores for drug-related AEs decreased from 10.01 ± 2.7 to 8.72 ± 3.52 (absolute risk difference 1.29; 95% confidence interval, 0.88-1.7; p < 0.01) following the introduction of the intervention. Conclusions: AEs occurred in the ICU with a typical diurnal frequency distribution. Medication-related AEs were the most prevalent. By applying the risk-index scores methodology, we were able to demonstrate that our multifaceted implementation strategy focused on medication-related adverse events allowed to decrease drug related incidents.
High accuracy of the nine equivalents of nursing manpower use score assessed by critical care nurses
Swiss Medical Weekly, 2012
The nine equivalents of nursing manpower use score (NEMS) is frequently used to quantify, evaluat... more The nine equivalents of nursing manpower use score (NEMS) is frequently used to quantify, evaluate and allocate nursing workload at intensive care unit level. In Switzerland it has also become a key component in defining the degree of ICU hospital reimbursement. The accuracy of nurse registered NEMS scores in real life was assessed and error-prone variables were identified. In this retrospective multicentre audit three reviewers (1 nurse, 2 intensivists) independently reassessed a total of 529 NEMS scores. Correlation and agreement of the sum-scores and of the different variables among reviewers, as well as between nurses and the reviewers&amp;#39; reference value, were assessed (ICC, % agreement and kappa). Bland &amp;amp; Altman (reference value - nurses) of sum-scores and regression of the difference were determined and a logistic regression model identifying risk factors for erroneous assessments was calculated. Agreement for sum-scores among reviewers was almost perfect (mean ICC = 0.99 / significant correlation p &amp;lt;0.0001). The nurse registered NEMS score (mean ± SD) was 24.8 ± 8.6 points versus 24.0 ± 8.6 points (p &amp;lt;0.13 for difference) of the reference value, with a slightly lower ICC (0.83). The lowest agreement was found in intravenous medication (0.85). Bland &amp;amp; Altman was 0.84 ± 10, with a significant regression between the difference and the reference value, indicating overall an overestimation of lower scores (≤29 points) and underestimation of higher scores. Accuracy of scores or variables was not associated with nurses&amp;#39; characteristics. In real life, nurse registered NEMS scores are highly accurate. Lower (≤29 points) NEMS sum-scores are overestimated and higher underestimated. Accuracy of scores or variables was not associated with nurses&amp;#39; characteristics.
Omitted and unjustified medications in the discharge summary
Quality and Safety in Health Care
Limited information exists in regard to drug omissions and unjustified medications in the hospita... more Limited information exists in regard to drug omissions and unjustified medications in the hospital discharge summary (DS). To evaluate the incidence and types of drug omissions and unjustified medications in the DS, and to assess their potential impact on patient health. A prospective observational review of the DSs of all patients discharged from our Internal Medicine Department over a 3-month period. Data assessment was made by internists using a structured form. Of the 577 evaluated DSs, 66% contained at least one inconsistency accounting for a total of 1012 irregularities. There were 393 drug omissions affecting 251 patients, 32% of which were potentially harmful. Seventeen per cent of all medications (619/3691) were unjustified, affecting 318 patients. The unjustified medication was potentially harmful in 16% of cases, occurred significantly more frequent in women than in men (61% vs 50%; p = 0.008) and increased linearly with the number of drugs prescribed (p<0.001). Drug o...
The Popliteal-Artery Entrapment Syndrome in a Patient Using Anabolic Steroids
New England Journal of Medicine, 2002
... N Engl J Med 2001;345:1727-33. 2. Pfister HW, Feiden W, Einhaupl KM. ... JOHN F. BRUZZI, MD D... more ... N Engl J Med 2001;345:1727-33. 2. Pfister HW, Feiden W, Einhaupl KM. ... JOHN F. BRUZZI, MD DARREN D. BRENNAN, MD Mater Misericordiae Hospital Dublin 7, Ireland bruzzij@hotmail.com To the Editor: Although the article by Hasbun et al. ...
RISUS SARDONICUS STILL BEYOND THE CORNER
Journal of the American Geriatrics Society, 2000
... RISUS SARDONICUS STILL BEYOND THE CORNER. Andreas Perren MD 1 ,; Mattia Lepori MD 2 ,; Pierlu... more ... RISUS SARDONICUS STILL BEYOND THE CORNER. Andreas Perren MD 1 ,; Mattia Lepori MD 2 ,; Pierluigi Pedrazzi MD 3 ,; Claudio Marone MD 4. ... 3 Neurology. 4 Internal Medicine, Ospedale Regionale Bellinzona e Valli, Bellinzona, Switzerland. Publication History. ...
Potassium Levels After Acute Myocardial Infarction
JAMA, 2012
European Journal of Intensive Care Medicine
The spontaneous breathing trial (SBT)-relying on objective criteria assessed by the clinician-is ... more The spontaneous breathing trial (SBT)-relying on objective criteria assessed by the clinician-is the major diagnostic tool to determine if patients can be successfully extubated. However, little is known regarding the patient's subjective perception of autonomous breathing. We performed a prospective observational study in 211 mechanically ventilated adult patients successfully completing a SBT. Patients were randomly assigned to be interviewed during this trial regarding their prediction of extubation success. We compared post-extubation outcomes in three patient groups: patients confident (confidents; n = 115) or not (non-confidents; n = 38) of their extubation success and patients not subjected to interview (control group; n = 58). Extubation success was more frequent in confidents than in non-confidents (90 vs. 45%; p < 0.001/positive likelihood ratio = 2.00) or in the control group (90 vs. 78%; p = 0.04). On the contrary, extubation failure was more common in non-confide...
The American Journal of Cardiology, 2007
Critically ill patients commonly show a decrease in hemoglobin concentration during their stay in... more Critically ill patients commonly show a decrease in hemoglobin concentration during their stay in the intensive care unit. The purpose of the present study was to evaluate whether nonbleeding patients with acute coronary syndrome (ACS) show a similar decrease of hemoglobin, and thereby furnish reference values and analyze possible mechanisms. In this retrospective, descriptive study, the charts of all patients with ACS hospitalized between January 2004 and September 2005 were screened with regard to patient characteristics, time course of hemoglobin, as well as clinical parameters, concomitant drug therapy, and fluid balances. One hundred three nonbleeding patients with ACS were analyzed. They showed an average hemoglobin decrease of 1.27 ؎ 1.00 g/dl (p <0.001). The decrease in hemoglobin level was observed during the first 12 to 24 hours; thereafter the hemoglobin concentration remained stable. We found a correlation among decrease of hemoglobin, parameters of stress, such as hypertension (p ؍ 0.019), tachycardia (p ؍ 0.004), pain (p ؍ 0.043), and white blood cells (p ؍ 0.021), as well as the intravenous administration of nitroglycerin (p ؍ 0.004). In conclusion, during the first 24 hours in the intensive care unit the hemoglobin concentration of nonbleeding patients with ACS regularly decreases at 1.27 ؎ 1.00 g/dl. Any further decrease in hemoglobin level beyond these values should entail early active search of the bleeding source. We hypothesize that this decrease is due to normalization of the previous stress-induced hemoconcentration and "internal hemodilution" by nitroglycerin.
[Non infectious postoperative fever]
Praxis
We present the case of a 74-years old man with subtotal gastrectomy for adenocarcinoma, whose pos... more We present the case of a 74-years old man with subtotal gastrectomy for adenocarcinoma, whose postoperative course is complicated by a prolonged fever. Despite extensive diagnostics, the origin of the postoperative fever remains unexplained for 47 days, when the patient is transferred to the ICU because of lethargy, hemodynamic instability, lung edema and abdominal symptoms. The diagnosis of Addison crisis is established and under substitution with hydrocortisone all the symptoms rapidly resolve. Postoperative fever is relatively frequent and infectious causes account for about half of the cases only. An infectious origin has imperatively to be excluded when the fever arises later than 48 hrs after surgery. In case of prolonged fever we suggest to extend the differential diagnosis to other than infectious causes by means of special lists (e.g fever of unknown origin).
A case of central alveolar hypoventilation in medullary thyroid cancer
Swiss medical weekly: official journal of the Swiss Society of Infectious Diseases, the Swiss Society of Internal Medicine, the Swiss Society of Pneumology
[ARDS in plasmodium vivax malaria]
Schweizerische medizinische Wochenschrift
Acute renal failure, disseminated intravascular coagulation, ARDS, hypoglycaemia, coma or epilept... more Acute renal failure, disseminated intravascular coagulation, ARDS, hypoglycaemia, coma or epileptic seizures are manifestations of severe Plasmodium falciparum malaria. On the other hand, vivax malaria or benign tertian malaria is usually free from complications. In the present report we describe a case of acute tertian malaria with a severe and complicated course. In this situation bacterial coinfection should always be suspected and treated empirically with broad-spectrum antibiotics, until the results of cultures are available. Mixed plasmodial infection (P. vivax and P. falciparum) must be excluded by repeated and meticulous examination of blood smears. Newer techniques such as PCR processing or ParaSight F Test are mentioned.
[Detection of hereditary hemochromatosis]
Revue médicale suisse
Hereditary hemochromatosis is one of the most common genetic disorders. The prognosis of hemochro... more Hereditary hemochromatosis is one of the most common genetic disorders. The prognosis of hemochromatosis is normal when phlebotomy therapy is started prior to manifestation of cirrhosis or diabetes. High ferritin is not always a marker of iron overload and ferritin must thus be coupled with transferrin saturation. Only high transferrin saturation entails a genetic research (HFE or type 1). The identification of rare types of hemochromatosis (types 2-4) is only required in particular cases. The evaluation of the iron overload is now based on hepatic MRI determination rather than liver biopsy.
Physical restraint in the ICU - does it prevent device removal? A critical appraisal
Minerva anestesiologica, Jan 12, 2014
Physical restraint is frequently used in the intensive care setting but little is known regarding... more Physical restraint is frequently used in the intensive care setting but little is known regarding its clinical scenario and effectiveness in preventing adverse events (AEs), defined as device removal. A prospective observational study in three Intensive Care Units on 120 adult high--risk patients. The effectiveness of physical restraint was evaluated using the propensity score methodology in order to obtain comparable groups. Physical restraint was applied in 1371 of 3256 (43%) nurse shifts accounting for 120 patients. Substantial agitation, the nurse&amp;#39;s judgement of insufficient sedation and sedative drug reduction were positively associated with physical restraint, whereas the presence of analgesics at admission, increased disease gravity and the treating hospital as the most substantial variable showed a negative association. Eighty--six AEs were observed in 44 patients. Quiet (SAS=1--4), unrestrained patients accounted for 40 cases, and agitated (SAS≥5) but physically restrained patients for 17 cases. The presence of any type of physical restraint had a protective effect against any type of AE (OR=0.28; CI 0.16-0.51). The observed AEs showed a limited impact on the patients&amp;#39; course of illness. No physical harm related to physical restraint was reported. Physical restraint efficiently averts AEs. Its application is mainly driven by local habits. Typically, the almost recovered, apparently calm and hence unrestrained patient is at greatest risk for undesirable device removal. The control/interpretation of the patient&amp;#39;s analgo--sedation might be inappropriate.
[Latin organ donation programme (LODP): an effective initiative to increase organ donation in Switzerland]
Revue médicale suisse, Jan 22, 2011
The 1st federal transplant law was enforced in July 2007 with the obligation to promote quality a... more The 1st federal transplant law was enforced in July 2007 with the obligation to promote quality and efficiency in the procedures for organ and tissue donation for transplantation. The Latin organ donation programme (LODP) created in 2008 aims to develop organ donation in 17 public hospitals in 7 Latin cantons, covering 2.2 million people; 29% of the Swiss population. The implementation of various effective measures by the LODP enabled the increase in the number of donors by 70% between 2008 and 2010, with four organs procured per donor; greatly exceeding the European average of three. The results show that LODP has successfully professionalised the system and we can only hope that similar organisations will be put into place throughout Switzerland.
Fluid balance in critically ill patients. Should we really rely on it?
Minerva anestesiologica, 2011
The computation of fluid balances (FBs) by subtracting fluid outputs from inputs is a common crit... more The computation of fluid balances (FBs) by subtracting fluid outputs from inputs is a common critical care practice. Limited information exists about the accuracy and consistency of nurse-registered cumulative FBs and regarding the value of suggested corrections for non-measurable losses. From 147 ICU patients, we prospectively evaluated the cumulative FBs and their relationship to changes in body weight (BW). Standardised measurements of BW were performed on admission and discharge. FB charts were accurately reviewed and arithmetic errors corrected. Net cumulative FBs and adjusted cumulative FBs (considering sensible or insensible fluid losses/fever/liquid faeces) were analysed for all patients and 3 subgroups (cardiac-cerebral, septic, and others). Agreement between FBs and BW changes was calculated according to the defined subgroups and confounding variables. Cumulative FBs were inaccurate in 49 cases (33%) with errors ranging from -3606 mL to +2020 mL. The total (average daily) ...
[Adverse internal medicine drug effects at hospital admission]
Schweizerische medizinische Wochenschrift, Jan 19, 1999
Hospital admissions due to adverse drug reactions are an important concern, but there are few dat... more Hospital admissions due to adverse drug reactions are an important concern, but there are few data concerning the specific situation in Switzerland. During one year we therefore prospectively studied all admissions to our medical department to determine the profile. 138 of 2168 patients presented a total of 150 adverse drug reactions at hospitalisation (6.4%) and among them 65% of the admissions were directly related to adverse drug reaction. Age stratification revealed that with each decade of age there was an increasing risk of adverse drug reactions and that the patients were sicker (more diagnoses), were consuming more drugs and had longer stays. The majority of adverse drug reactions were type A reactions and therefore potentially preventable. Cardio- and cerebrovascular drugs (diuretics, ACE-inhibitors, platelet aggregation inhibiting therapy) accounted for 65% of the side effects. Analysed by affected organ system, the most frequent adverse drug reactions were gastrointestina...
Postoperatives Fieber – nicht immer infektiöser Art
Praxis, 2007
Swiss medical weekly, 2014
The first description of the simplified acute physiology score (SAPS) II dates back to 1993, but ... more The first description of the simplified acute physiology score (SAPS) II dates back to 1993, but little is known about its accuracy in daily practice. Our purpose was to evaluate the accuracy of scoring and the factors that affect it in a nationwide survey. Twenty clinical scenarios, covering a broad range of illness severities, were randomly assigned to a convenience sample of physicians or nurses in Swiss adult intensive care units (ICUs), who were asked to assess the SAPS II score for a single scenario. These data were compared to a reference that was defined by five experienced researchers. The results were cross-matched with demographic characteristics and data on the training and quality control for the scoring, structural and organisational properties of each participating ICU. A total of 345 caregivers from 53 adult ICU providers completed the SAPS II evaluation of one clinical scenario. The mean SAPS II scoring was 42.6 ± 23.4, with a bias of +5.74 (95%CI 2.0-9.5) compared ...
The Difficulty of Measuring the Measurable
Respiratory Care, 2014
Critical Care Research and Practice, 2012
Background. Reliable ICU severity scores have been achieved by various healthcare workers but not... more Background. Reliable ICU severity scores have been achieved by various healthcare workers but nothing is known regarding the accuracy in real life of severity scores registered by untrained nurses. Methods. In this retrospective multicentre audit, three reviewers independently reassessed 120 SAPS II scores. Correlation and agreement of the sum-scores/variables among reviewers and between nurses and the reviewers' gold standard were assessed globally and for tertiles. Bland and Altman (gold standardnurses) of sum scores and regression of the difference were determined. A logistic regression model identifying risk factors for erroneous assessments was calculated. Results. Correlation for sum scores among reviewers was almost perfect (mean ICC = 0.985). The mean (±SD) nurse-registered SAPS II sum score was 40.3 ± 20.2 versus 44.2 ± 24.9 of the gold standard (P < 0.002 for difference) with a lower ICC (0.81). Bland and Altman assay was +3.8 ± 27.0 with a significant regression between the difference and the gold standard, indicating overall an overestimation (underestimation) of lower (higher; >32 points) scores. The lowest agreement was found in high SAPS II tertiles for haemodynamics (k = 0.45-0.51). Conclusions. In real life, nurse-registered SAPS II scores of very ill patients are inaccurate. Accuracy of scores was not associated with nurses' characteristics.
Annals of Intensive Care, 2012
Background: Adverse events (AEs) frequently occur in intensive care units (ICUs) and affect negat... more Background: Adverse events (AEs) frequently occur in intensive care units (ICUs) and affect negatively patient outcomes. Targeted improvement strategies for patient safety are difficult to evaluate because of the intrinsic limitations of reporting crude AE rates. Single interventions influence positively the quality of care, but a multifaceted approach has been tested only in selected cases. The present study was designed to evaluate the rate, types, and contributing factors of emerging AEs and test the hypothesis that a multifaceted intervention on medication might reduce drug-related AEs. Methods: This is a prospective, multicenter, before-and-after study of adult patients admitted to four ICUs during a 24-month period. Voluntary, anonymous, self-reporting of AEs was performed using a detailed, locally designed questionnaire. The temporal impact of a multifaceted implementation strategy to reduce drug-related AEs was evaluated using the risk-index scores methodology. Results: A total of 2,047 AEs were reported (32 events per 100 ICU patient admissions and 117.4 events per 1,000 ICU patient days) from 6,404 patients, totaling 17,434 patient days. Nurses submitted the majority of questionnaires (n = 1,781, 87%). AEs were eye-witnessed in 49% (n = 1,003) of cases and occurred preferentially during an elective procedure (n = 1,597, 78%) and on morning shifts (n = 1,003, 49%), with a peak rate occurring around 10 a.m. Drug-related AEs were the most prevalent (n = 984, 48%), mainly as a consequence of incorrect prescriptions. Poor communication among caregivers (n = 776) and noncompliance with internal guidelines (n = 525) were the most prevalent contributing factors for AE occurrence. The majority of AEs (n = 1155, 56.4%) was associated with minimal, temporary harm. Risk-index scores for drug-related AEs decreased from 10.01 ± 2.7 to 8.72 ± 3.52 (absolute risk difference 1.29; 95% confidence interval, 0.88-1.7; p < 0.01) following the introduction of the intervention. Conclusions: AEs occurred in the ICU with a typical diurnal frequency distribution. Medication-related AEs were the most prevalent. By applying the risk-index scores methodology, we were able to demonstrate that our multifaceted implementation strategy focused on medication-related adverse events allowed to decrease drug related incidents.
High accuracy of the nine equivalents of nursing manpower use score assessed by critical care nurses
Swiss Medical Weekly, 2012
The nine equivalents of nursing manpower use score (NEMS) is frequently used to quantify, evaluat... more The nine equivalents of nursing manpower use score (NEMS) is frequently used to quantify, evaluate and allocate nursing workload at intensive care unit level. In Switzerland it has also become a key component in defining the degree of ICU hospital reimbursement. The accuracy of nurse registered NEMS scores in real life was assessed and error-prone variables were identified. In this retrospective multicentre audit three reviewers (1 nurse, 2 intensivists) independently reassessed a total of 529 NEMS scores. Correlation and agreement of the sum-scores and of the different variables among reviewers, as well as between nurses and the reviewers&amp;#39; reference value, were assessed (ICC, % agreement and kappa). Bland &amp;amp; Altman (reference value - nurses) of sum-scores and regression of the difference were determined and a logistic regression model identifying risk factors for erroneous assessments was calculated. Agreement for sum-scores among reviewers was almost perfect (mean ICC = 0.99 / significant correlation p &amp;lt;0.0001). The nurse registered NEMS score (mean ± SD) was 24.8 ± 8.6 points versus 24.0 ± 8.6 points (p &amp;lt;0.13 for difference) of the reference value, with a slightly lower ICC (0.83). The lowest agreement was found in intravenous medication (0.85). Bland &amp;amp; Altman was 0.84 ± 10, with a significant regression between the difference and the reference value, indicating overall an overestimation of lower scores (≤29 points) and underestimation of higher scores. Accuracy of scores or variables was not associated with nurses&amp;#39; characteristics. In real life, nurse registered NEMS scores are highly accurate. Lower (≤29 points) NEMS sum-scores are overestimated and higher underestimated. Accuracy of scores or variables was not associated with nurses&amp;#39; characteristics.
Omitted and unjustified medications in the discharge summary
Quality and Safety in Health Care
Limited information exists in regard to drug omissions and unjustified medications in the hospita... more Limited information exists in regard to drug omissions and unjustified medications in the hospital discharge summary (DS). To evaluate the incidence and types of drug omissions and unjustified medications in the DS, and to assess their potential impact on patient health. A prospective observational review of the DSs of all patients discharged from our Internal Medicine Department over a 3-month period. Data assessment was made by internists using a structured form. Of the 577 evaluated DSs, 66% contained at least one inconsistency accounting for a total of 1012 irregularities. There were 393 drug omissions affecting 251 patients, 32% of which were potentially harmful. Seventeen per cent of all medications (619/3691) were unjustified, affecting 318 patients. The unjustified medication was potentially harmful in 16% of cases, occurred significantly more frequent in women than in men (61% vs 50%; p = 0.008) and increased linearly with the number of drugs prescribed (p<0.001). Drug o...
The Popliteal-Artery Entrapment Syndrome in a Patient Using Anabolic Steroids
New England Journal of Medicine, 2002
... N Engl J Med 2001;345:1727-33. 2. Pfister HW, Feiden W, Einhaupl KM. ... JOHN F. BRUZZI, MD D... more ... N Engl J Med 2001;345:1727-33. 2. Pfister HW, Feiden W, Einhaupl KM. ... JOHN F. BRUZZI, MD DARREN D. BRENNAN, MD Mater Misericordiae Hospital Dublin 7, Ireland bruzzij@hotmail.com To the Editor: Although the article by Hasbun et al. ...
RISUS SARDONICUS STILL BEYOND THE CORNER
Journal of the American Geriatrics Society, 2000
... RISUS SARDONICUS STILL BEYOND THE CORNER. Andreas Perren MD 1 ,; Mattia Lepori MD 2 ,; Pierlu... more ... RISUS SARDONICUS STILL BEYOND THE CORNER. Andreas Perren MD 1 ,; Mattia Lepori MD 2 ,; Pierluigi Pedrazzi MD 3 ,; Claudio Marone MD 4. ... 3 Neurology. 4 Internal Medicine, Ospedale Regionale Bellinzona e Valli, Bellinzona, Switzerland. Publication History. ...
Potassium Levels After Acute Myocardial Infarction
JAMA, 2012
European Journal of Intensive Care Medicine
The spontaneous breathing trial (SBT)-relying on objective criteria assessed by the clinician-is ... more The spontaneous breathing trial (SBT)-relying on objective criteria assessed by the clinician-is the major diagnostic tool to determine if patients can be successfully extubated. However, little is known regarding the patient's subjective perception of autonomous breathing. We performed a prospective observational study in 211 mechanically ventilated adult patients successfully completing a SBT. Patients were randomly assigned to be interviewed during this trial regarding their prediction of extubation success. We compared post-extubation outcomes in three patient groups: patients confident (confidents; n = 115) or not (non-confidents; n = 38) of their extubation success and patients not subjected to interview (control group; n = 58). Extubation success was more frequent in confidents than in non-confidents (90 vs. 45%; p < 0.001/positive likelihood ratio = 2.00) or in the control group (90 vs. 78%; p = 0.04). On the contrary, extubation failure was more common in non-confide...