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Dieses Dokument zur „Struktur und Ausstattung von Intensivstationen“ der Deutschen Interdisziplinären Vereinigung für Intensiv- und Notfallmedizin e. V. (DIVI) soll Empfehlungen zur personellen Ausstattung, zur Infrastruktur und zur Organisation von Intensivstationen geben. Die Empfehlungen basieren auf einer systematischen Literaturrecherche und einem formalen Konsensprozess einer interdisziplinären und interprofessionellen Gruppe von Spezialisten der DIVI. Die Empfehlungen beschreiben eine Einteilung von Intensivstationen in 3 Stufen, eine Einteilung der Patienten entsprechend ihrer Erkrankungsschwere in 3 Stufen, die personelle Ausstattung mit Ärzten, Pflegekräften, Therapeuten ebenso wie mit Stationsapothekern, Psychologen und weiteren Spezialisten. Weiterhin werden Empfehlungen zur apparativen Ausstattung und zur baulichen Ausführung ausgesprochen

ABSTRACTAdequate linezolid blood concentrations have been shown to be associated with an improved clinical outcome. Our goal was to assess new predictors of inadequate linezolid concentrations often observed in critically ill patients. Fifty-two critically ill patients with severe infections receiving standard dosing of linezolid participated in this prospective observational study. Serum samples (median, 32 per patient) were taken on four consecutive days, and total linezolid concentrations were quantified. Covariates influencing linezolid pharmacokinetics were identified by multivariate analysis and a population pharmacokinetic model. Target attainment (area under the concentration-time curve over 12 h [AUC12]/MIC ratio of >50; MIC = 2 mg/liter) was calculated for both the study patients and a simulated independent patient group (n= 67,000). Target attainment was observed for only 36% of the population on both days 1 and 4. Independent covariates related to significant decreases of linezolid concentrations included higher weight, creatinine clearance rates, and fibrinogen and antithrombin concentrations, lower concentrations of lactate, and the presence of acute respiratory distress syndrome (ARDS). Linezolid clearance was increased in ARDS patients (by 82%) and in patients with elevated fibrinogen or decreased lactate concentrations. In simulated patients, most covariates, including fibrinogen and lactate concentrations and weight, showed quantitatively minor effects on target attainment (difference of ≤9% between the first and fourth quartiles of the respective parameters). In contrast, the presence of ARDS had the strongest influence, with only ≤6% of simulated patients reaching this target. In conclusion, the presence of ARDS was identified as a new and strong predictor of insufficient linezolid concentrations, which might cause treatment failure. Insufficient concentrations might also be a major problem in patients with combined alterations of other covariate parameters. (This study has been registered at ClinicalTrials.gov under registration number NCT01793012.)

We describe a young patient who ingested 18 g (240 times the daily therapeutic dose) of venlafaxine in a suicide attempt. She developed severe cardiomyopathy in a takotsubo distribution causing cardiogenic shock and multi-organ dysfunction syndrome (MODS). She was successfully treated with intravenous lipid emulsion (ILE), extracorporeal life support (ECLS) and CytoSorb®. This is remarkable as, to the best of the authors’ knowledge, this is the highest amount of venlafaxine intake seen in the literature with a nonfatal outcome.

Mit der tonometrischen Bestimmung des Mukosa-pH-Wertes können nichtinvasiv Informationen über das Verhältnis von Sauerstoffangebot und Sauerstoffbedarf der gastrointestinalen Mukosa gewonnen werden. Die Technik der tonometrischen pHi-Bestimmung ist einfach zu handhaben; für die klinische Anwendung stehen kommerziell erhältliche Tonometriekatheter zur Verfügung (Tonometrics®). Zur Ermittlung des pHi-Wertes werden der pCO2 in der Füllflüssigkeit des im Magen oder im Sigma plazierten Tonometriekatheterballons und die Bikarbonatkonzentration in einer arteriellen Blutprobe bestimmt; der pHi wird mit Hilfe der Henderson-Hasselbalch-Gleichung errechnet. Experimentell wurde die tonometrische pHi-Bestimmung validiert und die Abhängigkeit des pHi vom lokalen Sauerstoffangebot an die Mukosa nachgewiesen. Bei chirurgischen Patienten hatte der pHi-Wert hohe prognostische Wertigkeit für das Auftreten von Komplikationen und für die Überlebenswahrscheinlichkeit. Bei Intensivpatienten mit Mukosaazidose konnte durch die Optimierung der Intensivtherapie anhand des pHi-Wertes eine Verbesserung der Überlebensrate erreicht werden. Für die Bestimmung des tatsächlichen Stellenwertes der tonometrischen Bestimmung des Mukosa-pH sind weitere Studien an exakt stratifizierten Patientengrup-pen mit definierten Interventionsgrenzen und genauen, auf die Verbesserung der Sauerstoffversorgung abzielenden, Therapieprotokollen erforderlich. Die pHi-Messung scheint nach den vorliegenden Informationen ein wertvolles Monitoringverfahren zu sein, das wichtige Informationen über die lokale Sauerstoffversorgung der gastrointestinalen Mukosa liefern, Rückschlüsse auf die Prognose des Patienten ermöglichen und die Notwendigkeit von Therapiemaßnahmen zur Verbesserung der Gewebeoxygenierung anzeigen kann.

Bronchiolitis obliterans syndrome (BOS) is the limiting factor to long-term survival after lung transplantation. Previous studies suggested respiratory viral tract infections are associated with the development of BOS. To identify the impact of virus detection in bronchoalveolar lavage (BAL) fluid, we analyzed BAL samples from 87 consecutive lung transplant recipients for human herpesvirus (HHV)-6, Epstein-Barr virus, Herpes simplex virus 1/2, Cytomegalovirus, respiratory syncytical virus and adenovirus by PCR. Acute rejection, BOS and death were recorded for a mean follow-up time of 3.27 ± 0.47 years. Results of PCR analysis and other potential risk factors were entered into a Cox regression analysis of BOS predictors and death. Only acute rejection was a distinct risk factor for BOS of all stages, death and death from BOS. HHV-6 was detected in 20 patients. Univariate and multivariate analysis revealed that HHV-6 was associated with an increased risk to develop BOS ≥ stage 1 and death, separate from the risk attributable to acute rejection. Identification of HHV-6 DNA in BAL fluid is a potential risk factor for BOS. Our results warrant further studies to elucidate a possible causal link between HHV-6 and BOS.

Bronchiolitis obliterans syndrome (BOS) is the limiting factor to long‐term survival after lung transplantation. Previous studies suggested respiratory viral tract infections are associated with the development of BOS. To identify the impact of virus detection in bronchoalveolar lavage (BAL) fluid, we analyzed BAL samples from 87 consecutive lung transplant recipients for human herpesvirus (HHV)‐6, Epstein‐Barr virus, Herpes simplex virus 1/2, Cytomegalovirus, respiratory syncytical virus and adenovirus by PCR. Acute rejection, BOS and death were recorded for a mean follow‐up time of 3.27 ± 0.47 years. Results of PCR analysis and other potential risk factors were entered into a Cox regression analysis of BOS predictors and death. Only acute rejection was a distinct risk factor for BOS of all stages, death and death from BOS. HHV‐6 was detected in 20 patients. Univariate and multivariate analysis revealed that HHV‐6 was associated with an increased risk to develop BOS ≥ stage 1 and death, separate from the risk attributable to acute rejection. Identification of HHV‐6 DNA in BAL fluid is a potential risk factor for BOS. Our results warrant further studies to elucidate a possible causal link between HHV‐6 and BOS.

Acute rejection and diffuse alveolar damage are major problems during the early time after transplantation. Against this background, lung biopsies after allogeneic lung transplantation were studied using immunohistochemistry. Biopsies with acute rejection, diffuse alveolar damage and morphological inconspicuous biopsies were chosen. The objectives of this study were to ascertain: (a) if and how CD4 and CD8 T cells contribute to allograft rejection and diffuse alveolar damage, (b) whether there is a correlation of the chemoattractant regulated on activation normal T cells (RANTES) with the mononuclear infiltrate and (c) whether perforin/granzyme and Fas/FasL pathways contribute to lung injury after lung transplantation. Our results show that CD4 + and CD8 + T cells were increased in biopsies with acute rejection and, to a minor extent, also in biopsies with diffuse alveolar damage due to reperfusion injury. RANTES expression of T cells was increased in biopsies with acute rejection. Perforin seemed to have a dual role in the alloimmune response. In one regard, it had a cytolytic function in the acute rejection process, and, in contrast, it may be responsible for downregulating both CD4- and CD8-mediated alloimmune responses. The FasL/Fas pathway is not only important for induction of apoptosis during rejection but is also a mechanism of lung injury in the development of diffuse alveolar damage.

Small-volume resuscitation of severe hypovolemia and shock by means of hyperosmotic/hyperoncotic solutions is used for the rapid restoration of macrohemodynamics and prevention of early deaths. In addition, it has emerged that it may help in the prevention of late complications such as sepsis, multiple systems organ failure (MSOF), which result from persisting microcirculatory disturbances. The novelty of the concept is based upon its mechanisms of action at the microcirculatory and cellular level.

The most prominent advances in the management of patients with chronic renal failure and recent findings in the pathophysiology and pharmacology relevant to treatment in the perioperative period are reviewed. The treatment of uraemic anaemia with recombinant erythropoietin may reduce the need for blood transfusions. The pharmacological properties of calcium antagonists have stimulated researchers to find their therapeutic potential in patients with renal dysfunction and with hypertension. The growing shortage of kidneys for transplantation calls for improving immunosuppressive therapy of the recipients and for developing new donor programmes. The use of kidneys from donors with ceased blood circulation has been suggested.

Die Erörterung der Gestose im Rahmen der Weiterbildungsreihe einer anaesthesiologischen Fachzeitschrift scheint nur auf den ersten Blick verwunderlich. Die vielgestaltige Symptomatik der Erkrankung, die teilweise dramatische Progredienz der Krankheitssymptome und das Fehlen einer kausalen Therapie erfordern eine hohe Fachkompetenz aller an der Behandlung von Gestosepatientinnen beteiligten Ärzte. In diesem Beitrag werden die wichtigsten Erkenntnisse zum Erkrankungskomplex "Gestose" zusammengefaßt, die für die anästhesiologische und intensivmedizinische Behandlung von Patientinnen mit Gestose bedeutsam sind.

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A 20-year-old man without any history of a pulmonary disease presented initially with a 1-day history of fever and tachypnea and developed an acute respiratory failure within 24hours. Microbiological and histological examinations raised an invasive pulmonary aspergillosis (IPA). A chronic granulomatous disease was identified as the predisposing factor leading to this severe fungal infection. Chronic granulomatous disease is caused by a reduced ability of phagocytes to mount an oxidative burst due to a defect in the nicotinamide adenine dinucleotide phosphate oxidase. Although IPA occurs usually in severely immunocompromised patients, it should be kept in mind that there are an increasing number of cases developing IPA in the setting of apparent health or to date undiagnosed immunodeficiency that requires further diagnostics.

In acute respiratory distress syndrome (ARDS) with severe hypoxemia or respiratory acidosis, veno-venous extracorporeal membrane oxygenation (VV-ECMO) ensures oxygenation and decarboxylation. Commonly, simultaneous cannulation of jugular and femoral veins is used for VV-ECMO. A recently introduced dual-lumen cannula for VV-ECMO promises single vessel access through the right internal jugular vein and patient ambulation. However, correct direction of the reinfusion jet toward the tricuspid valve during ECMO treatment requires more demanding cannula placement control. We present a new ultrasound-guided technique for the placement of a dual-lumen VV-ECMO cannula in a patient with ARDS and extreme obesity.

Secondary sclerosing cholangitis is a severe disease of the biliary tract. Over the last decade, several cases of sclerosing cholangitis in critically ill patients (SC-CIP) were reported. Reports in the literature so far are characterized by a wide variety of underlying causes of critical illness, thereby hindering a risk-factor analysis. We report on a homogenous cohort of critically ill patients with influenza A (H1N1) pneumonia and severe acute respiratory distress syndrome (ARDS), of whom a subgroup developed sclerosing cholangitis, allowing for probing of risk factors associated with SC-CIP.