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The number of organs donated after brain death in Germany is far lower than the demand. This underlines the importance of providing the brain-dead donor with optimal medical care throughout the donation process to decrease the risk of graft dysfunction. Several international guidelines and national recommendations guide the intensivists in organ-protective intensive care management of the brain-dead donor.The anesthetist is a key member during organ retrieval procedures and plays a crucial role in physiological donor management; however, evidence-based recommendations for the perioperative anesthetic management, drug treatment strategies and target values are lacking. Anesthesia literature about donor management is scarce and predominantly composed of reviews of practice, with little exploration of the scientific foundations. The aim of this review is to guide the anesthetist in the organ-protective perioperative therapy. The pathophysiological changes in patients who progress to brain death are briefly summarized. The available evidence, guidelines and expert opinions regarding medical treatment strategies and therapeutic goals in organ-protective therapy are reviewed. The ethical and pathophysiological considerations regarding the performance of anesthesia during organ retrieval are discussed.This review is based on a selective literature search in PubMed for publications regarding organ donation after brain death (keywords: "brain dead donor", "organ procurement", "organ protective therapy", "donor preconditioning", "perioperative donor management", "ethical considerations of brain dead donor"). International guidelines, national recommendations and expert opinions were given special consideration.Overall, the evidence for optimal perioperative organ-protective care of the brain-dead donor is limited. Most elements in the current recommendations and guidelines are based on pathophysiological reasoning, epidemiological observations or extrapolations from general organ-protective management strategies, and not on evidence from randomized controlled trials. National and international recommendations on treatment goals and drug therapy differ considerably in some aspects. The therapy concepts applied are very heterogeneous. Apart from medical challenges, the ethical circumstances are an additional burden for the entire treatment team. Whether anesthesia is reasonable during organ retrieval remains unclear. There is uncertainty about possible organ-protective effects of anesthetic drugs. Furthermore, ethical considerations raise the question of whether the determination of brain death and the use of anesthetic drugs during the procedure of organ retrieval are compatible with each other.Due to the lack of evidence, perioperative treatment should be guided by intensive care therapy strategies. The discussion about using anesthetic drugs during organ retrieval remains controversial. Pathophysiological considerations support the use of volatile anesthetics because of possible organ-protective effects. The use of neuromuscular blocking is justified to control any possible motor response resulting from spinal cord reflexes, whereas there is no evidence for a benefit from using opioids. Apart from that, it seems ethically problematic to anesthetise a brain-dead donor. Consequently, knowledge about the pathophysiological processes caused by brain death and about organ-protective therapy concepts are just as much a basic requirement as the consideration of ethical problems in organ donation after brain death. Only then are the caregivers able to do justice to both the organ recipient and the organ donor, as well as their relatives in this challenging situation.HINTERGRUND: Die Anzahl postmortal gespendeter Organe ist in Deutschland weit geringer als der Bedarf. Dies unterstreicht die Wichtigkeit einer optimalen Versorgung während des gesamten Prozesses der Organspende.Es existieren internationale Leitlinien und nationale Empfehlungen zu intensivmedizinischen organprotektiven Maßnahmen beim Organspender. Für das anästhesiologische Management fehlen evidenzbasierte Empfehlungen. Ziel dieser Übersichtsarbeit ist es, anhand der vorhandenen Evidenz die pathophysiologischen Veränderungen des irreversiblen Hirnfunktionsausfalls zu rekapitulieren und sich kritisch mit den empfohlenen Behandlungsstrategien und therapeutischen Zielgrößen auseinanderzusetzen. Auch auf ethische Aspekte der Betreuung des postmortalen Organspenders wird eingegangen.Diese Übersichtsarbeit basiert auf einer selektiven Literaturrecherche in PubMed (Suchwörter: „brain dead donor“, „organ procurement“, „organ protective therapy“, „donor preconditioning“, „perioperative donor management“, „ethical considerations of brain dead donor“). Internationale Leitlinien und nationale Empfehlungen wurden besonders berücksichtigt.Insgesamt ist die Evidenz für optimale intensivmedizinische und perioperative organprotektive Maßnahmen beim postmortalen Organspender sehr gering. Nationale und internationale Empfehlungen zu Zielwerten und medikamentösen Behandlungsstrategien unterscheiden sich teilweise erheblich: kontrollierte randomisierte Studien fehlen. Der Stellenwert einer Narkose zur Explantation bleibt sowohl unter pathophysiologischen Gesichtspunkten als auch aus ethischer Sicht ungeklärt.Die Kenntnisse über die pathophysiologischen Prozesse im Rahmen des irreversiblen Hirnfunktionsausfalls und die organprotektiven Maßnahmen sind ebenso Grundvoraussetzung wie die ethische Auseinandersetzung mit dem Thema postmortale Organspende. Nur dann kann das Behandlungsteam in dieser herausfordernden Situation sowohl dem Organempfänger als auch dem Organspender und seinen Angehörigen gerecht werden.

Die Nierenersatztherapie ist neben der Beatmung eines der wichtigsten und am häufigsten angewendeten Organersatzverfahren in der täglichen Praxis in der Intensivmedizin. Im Gegensatz zur Beatmungstherapie sind Qualitätsstandards für die Nierenersatztherapie weniger gut definiert und bekannt. In diesem Positionspapier der Deutschen Interdisziplinären Vereinigung für Intensivmedizin (DIVI) beschreiben wir Qualitätsstandards zur Nierenersatztherapie mit dem Ziel die Behandlungsqualität der Patienten mit einem schweren akuten Nierenversagen zu verbessern.

Renal replacement therapy (RRT) remains the cornerstone of treatment for severe acute kidney injury. However, despite its spreading use along with rising incidences of acute kidney injury, evidence of most recommendations is limited so far. Early initiation of RRT seems to reduce mortality but is associated with higher incidence of adverse events. Continuous RRT is advantageous in terms of hemodynamic control and decreased incidence of chronic dialysis dependency but without affecting mortality. Regional citrate anticoagulation should be preferred with regard to longer filter circuit life span. Intensified RRT with a prescribed dose ≥ 35 mL/kg/h has no benefit with regard to mortality but is associated with higher occurrence of complications. Urine output has the best prognostic value for cessation of RRT. Biomarkers of renal impairment and recovery are needed for better guidance of therapy.Die steigende Inzidenz der schweren akuten Nierenschädigung in Verbindung mit weiterhin hohen Mortalitätsraten stellt die intensivmedizinische Versorgung vor eine wachsende Herausforderung. Nierenersatzverfahren sind die wichtigste Therapiemaßnahme und kommen gleichermaßen zunehmend zum Einsatz – ungeachtet dessen werden wesentliche Aspekte ihrer Umsetzung infolge einer eingeschränkten Evidenzlage kontrovers diskutiert.

Surgical interventions and invasive procedures can trigger an inflammatory reaction in patients. This inflammatory reaction is an inherent response by the body and can be triggered by different stimuli, including the surgical tissue trauma itself and also by the administration of drugs commonly used for the induction and maintenance of general anesthesia.Immune system activation is mostly beneficial for the host defense against various exogenous pathogens during infectious disorders; however, if uncontrolled and overshooting or in the case of excessive immune system activation as a consequence of sterile inflammation, the inflammatory host response may also carry the risk for tissue and organ damage, which might severely threaten the patient. The aim of this article is to identify the causal factors of a perioperative immune reaction and to present interventional options.An extensive MEDLINE search was carried out on the perioperative and postoperative inflammatory response in the field of clinical and basic research.Current publications provide essential information on how surgical patients may be affected by overshooting inflammatory responses. Thus, the choice of administered anesthetic agent and the surgical trauma itself in addition to a supportive therapy may modulate perioperative inflammation in the perioperative phase. The effects on the patient can be multifarious.This article discusses the causes and effects of inflammatory processes in the perioperative phase. Additionally, it highlights the immunomodulatory effects of perioperatively administered therapeutics and anesthetics. Knowledge of this topic enables the reader to make qualified decisions in the perioperative setting to improve the individual patient outcome.

The incidence of acute kidney injury (AKI) has increased over the last decades. Renal replacement therapy (RRT) is increasingly being used. The Kidney Disease: Improving Global Outcomes (KDIGO) guidelines define AKI by serum creatinine (SCr) elevation and decrease in urinary output (UO) and suggest prevention strategies and recommendations on the management of RRT. Treatment options are limited and RRT remains the gold standard as supportive treatment but implies a substantial escalation of treatment. With respect to the indications and management of RRT, there are only a few evidence-based recommendations.This review summarizes the clinical relevance of AKI and presents the most important aspects on the indications and implementation of RRT.The available evidence is summarized based on the current literature.Implementation of the KDIGO bundles to prevent AKI in high-risk patients reduces the incidence of AKI. In the absence of absolute indications, the evidence-based recommendations on when to initiate RRT are limited and controversial. Intermittent hemodialysis (IHD) and continuous renal replacement therapy (CRRT) procedures can be considered as complementary therapeutic strategies. The CRRT is recommended in hemodynamically unstable patients. Regional citrate anticoagulation is the recommended anticoagulation in CRRT. The optimal effluent dose is effectively 20-25 ml/kg body weight and hour. Spontaneous diuresis is a best predictor of successful cessation of RRT.Risk identification and prevention of AKI are essential. In the absence of absolute indications, initiation and accomplishment of RRT should be patient-adapted and carried out in the clinical context. Newly developed biomarkers could be helpful in the future for a better estimation of the prognosis and for a more precise definition of therapeutic strategies of RRT.

Adults with congenital heart disease (CHD) represent an increasing proportion of patients undergoing non-cardiac surgery.To identify the most important parameters for management of anesthesia.Evaluation and discussion of the current original research and guideline recommendations.There are approximately 300,000 patients with CHD living in Germany. The preoperative evaluation is an important influencing factor affecting perioperative morbidity and mortality. Echocardiography is the key instrument for identifying cardiac conditions predisposing to adverse events. The subdivision of CHD into lesions with left-to-right shunt, obstructive lesions and complex congenital heart diseases facilitates the classification of the pathophysiology.Decisive for the perioperative outcome of patients with CHD are the identification of high-risk patients, understanding of the individual situation with respect to the underlying pathophysiology and the intraoperative maintenance of cardiac output.

Regional citrate anticoagulation (RCA) in continuous renal replacement therapy can effectively anticoagulate dialysis circuits without having adverse effects on systemic heparin application. In particular, in continuous renal replacement therapy RCA is well established and represents a safe procedure with longer filter lifetimes and fewer bleeding complications.To provide guidance on the indications, advantages and disadvantages, and use of RCA, current recommendations from the renal section of the DGIIN (Deutschen Gesellschaft für Internistische Intensivmedizin und Notfallmedizin), ÖGIAIN (Österreichischen Gesellschaft für Internistische und Allgemeine Intensivmedizin und Notfallmedizin) and DIVI (Deutschen Interdisziplinären Vereinigung für Intensiv- und Notfallmedizin) are stated.The recommendations in this paper are based on the current KDIGO (Kidney Disease: Improving Global Outcomes) guidelines, other published guidelines and protocols as well as the expert knowledge and clinical experience of the authors.The use of commercially available machines with coupled pumps and integrated safety features, effective personal training and standardized protocols for clinical usage (SOP) is particularly important for the safe clinical use of RCA in renal replacement therapy. Contrary to previous recommendations, even liver failure or shock with lactic acidosis may no longer be an absolute contra-indication for RCA. However, these particular patients have to be carefully monitored for signs of citrate accumulation.

Intensive care patients with renal failure or insufficiency comprise a heterogeneous group of subjects with widely differing metabolic patterns and nutritional requirements. They include subjects with various stages of acute kidney injury (AKI), acute-on-chronic renal failure (A-CKD), without/with renal replacement therapy (RRT), chronic kidney disease (CKD), and subjects on regular hemodialysis or peritoneal dialysis therapy (HD/PD).Development of recommendations by the renal section of DGIIN (Deutsche Gesellschaft für Internistische Intensivmedizin und Notfallmedizin), ÖGIAIN (Österreichische Gesellschaft für Internistische und Allgemeine Intensivmedizin und Notfallmedizin) and DIVI (Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin) for the metabolic management and the planning, indication, implementation, and monitoring of nutrition therapy in this heterogeneous group of patients.The recommendations are based on recent evidence and current recommendations of DGEM (Deutsche Gesellschaft für Ernährungsmedizin), ASPEN (American Society for Parenteral and Enteral Nutrition) and ESPEN (European Society for Clinical Nutrition and Metabolism) and also the KDGIO (Kidney Disease: Improving Global Outcomes) clinical practice guidelines for AKI and the expert knowledge and clinical experience of the authors.Nutrition support in these patient groups is not fundamentally different from that in other disease states but must consider the multiple variations in metabolism and nutrient requirements. Nutrition therapy must be adapted to the stage of disease and especially, in those patients on RRT. Nutritional needs can differ widely between patients but also in the same patient during the course of the disease.Thus, the patient with renal failure requires an individualized approach in nutrition support and because of the altered metabolism of many nutrients and intolerances for electrolytes and fluids, the nutrition support in patients with renal insufficiency requires close clinical and laboratory monitoring.

Acute kidney injury (AKI) is a common complication in intensive care unit (ICU) patients. The incidence of AKI in ICU patients exceeds 50% and the associated morbidity and mortality rates increase with severity of AKI. In addition, long-term consequences of AKI are underestimated and several studies show impaired long-term outcome after AKI. In about 5-25% of ICU patients with AKI renal replacement therapy (RRT) is required.To assist in indication, timing, modality and application of renal replacement therapy of adult patients, current recommendations from the renal sections of the DGIIN (Deutschen Gesellschaft für Internistische Intensivmedizin und Notfallmedizin), ÖGIAIN (Österreichischen Gesellschaft für Internistische und Allgemeine Intensivmedizin und Notfallmedizin) and DIVI (Deutschen Interdisziplinären Vereinigung für Intensiv- und Notfallmedizin) are stated.The recommendations stated in this paper are based on the current KDIGO (Kidney Disease: Improving Global Outcomes) guidelines, recommendations from the 17th Acute Disease Quality Initiative (ADQI) Consensus Group, the French Intensive Care Society (SRLF) with the French Society of Anesthesia Intensive Care (SFAR) and the expert knowledge and clinical experience of the authors.Today, different treatment modalities for RRT are available. Although continuous RRT and intermittent dialysis therapy as well as continuous dialysis therapy have comparable outcomes, differences exist with respect to practical application as well as health-economic aspects. Individualized risk stratification might be helpful to choose the right time to start and the right treatment modality for patients.

Many anti-infective drugs require dose adjustments in critically ill patients with acute kidney injury (AKI) and renal replacement therapy, in order to achieve adequate therapeutic drug concentrations.The fundamental pharmacokinetic and pharmacodynamic principles of drug dose adjustment are presented. Recommendations on anti-infective drug dosage in intensive care are provided.We established dose recommendations of selected anti-infective drugs based on information in the summary of product characteristics, published studies and recommendations, pharmacokinetic and pharmacodynamic considerations, and the experience and expert opinion of the authors.Out of a total of 37 anti-infective drugs (31 antibiotics, 2 antivirals, 4 antifungals) 8 can be administered independent of renal function. For 29 anti-infective drugs, a specific recommendation on drug dosage could be made in case of intermittent hemodialysis and for 24 anti-infective drugs in case of continuous hemo(dia)filtration.Recommendations on dosing of important anti-infective drugs in critically ill patients with AKI and renal replacement therapy are provided.

Acute kidney injury is a common and serious complication with a huge impact on morbidity and short- as well as long-term mortality. Sepsis and major surgeries, especially cardiac surgery, are the most common causes of acute kidney injury. Slight increases of serum-creatinine levels are associated with adverse outcomes highlighting the relevance of the need for nephroprotective strategies to reduce the occurrence of acute kidney injury. Remote ischaemic preconditioning is an intervention consisting of brief episodes of ischaemia and reperfusion at a remote site before subsequent ischaemic insults occur. This simple and uncomplicated method may offer an effective nephroprotective strategy.

The incidence of acute kidney injury (AKI) in critically ill patients is very high and is associated with an increased morbidity and mortality. In 2012 the Kidney Disease: Improving Global Outcome (KDIGO) guidelines were published in which evidence-based practical recommendations are given for the evaluation and management of patients with AKI. The first section of the KDIGO guidelines deals with the unification of earlier consensus definitions and staging criteria for AKI. The subsequent sections of the guidelines cover the prevention and treatment of AKI as well as the management of renal replacement therapy (RRT) in patients with AKI. In each section the existing evidence is discussed and a specific treatment recommendation is given. The guidelines appreciates that there is insufficient evidence for many of the recommendations. As a specific pharmacological therapy is missing, an early diagnosis, aggressive hemodynamic optimization, tight volume control, and avoidance of nephrotoxic drugs are the only interventions to prevent AKI. If renal replacement therapy is required different modalities are available to provide an effective therapy with a low rate of adverse effects.

In the 10 years since schema therapy was first recognized in Germany it has become widespread among practitioners and has taken a place among the so-called third wave therapies. The overall goal of schema therapy is conceptualizing and treating personality disorders or traits reinforcing axis I disorders. Early maladaptive schemas result from a child's unmet emotional core needs. In a limited reparenting therapy relationship these interpersonal situations are re-experienced and rescripted under the therapist's control. Schema therapy integrates elements of existing models and techniques into a consistent case conceptualization as the bedrock for understanding and changing maladaptive coping behavior. This review article gives a comprehensive overview about the model, the therapy relationship and the application of the experiential techniques in relation to already developed approaches (including the current evidence). The strengths and weaknesses are briefly discussed.

Zielsetzung: In der Intensivmedizin haben sich Verfahren der extrakorporalen Lungenunterstützung etabliert. Unklar ist, in wie weit ein intraoperativer Einsatz Sicherheit bietet und Operationen bei kritisch kranken Patienten mit respiratorischen Limitierungen ermöglicht. Methoden: Retrospektiv[for full text, please go to the a.m. URL], Gemeinsame Jahrestagung der Deutschen, Österreichischen und Schweizerischen Gesellschaft für Thoraxchirurgie

Metalloxide sind die derzeit wichtigsten kommerziell verarbeiteten Nanopartikel (NPs). Ziel dieser Arbeit war es, synthetisch hergestellte NPs auf Silika- und Zirkoniumdioxid-Basis zu charakterisieren und Interaktionen mit vor allem humanen Alveolarmakrophagen zu untersuchen. In Makrophagen konnte via MTT-Test erst bei hohen Konzentrationen eine akute Toxizität durch ZrO2-NPs nachgewiesen werden. Mikroskopische Aufnahmen von perinukleär lokalisierten Teilchenclustern der untersuchten SiO2-NPs wurden als Grundlage zur Erforschung der intrazellulären Teilchen-Dynamik verwendet. Die Quantifizierung des für die meisten zellulären Aufnahmeprozesse essentiellen F-Aktins ergab nach Inkubation mit NPs einen Anstieg des fibrillären Aktingehalts. Als zentrale Regulatoren der Aktin-Dynamik wurden die kleinen Rho-GTPasen (RhoA, Rac1 und Cdc42) auf einen veränderten Aktivierungsgrad nach Inkubation mit SiO2-NPs untersucht. Ob und wie stark die Rho-GTPasen aktiviert wurden, war dabei abhängig von der jeweils zu betrachtenden GTPase, Oberflächenmodifikation und Konzentration der Partikel, sowie der jeweiligen Zellspezies. In humanen Interstitiellen Makrophagen konnte nach Exposition von nicht-PEGylierten SiO2-NPs via EMSA eine erhöhte Aktivierung des Transkriptionsfaktors NF-kB gezeigt werden. Die Ergebnisse dieser Arbeit sollen dazu beitragen, die Toxizität und das inflammatorische Potential der verwendeten Nanomaterialien realistisch einzuschätzen. There is an increasing exposition of humans to engineered Nanoparticles (NPs) that are present in a wide range of commercially available products, consisting of metal oxides representing actually the commercially most important NPs. Aim of this dissertation was to characterize technical silica and zirconium nanoparticles and to investigate the interactions with human lung macrophages. In macrophages, an acute toxicitiy was shown for zirconia NPs in high concentrations after an incubation time of 24 hours. Based on the microscopic images, it has been possible to develop a stochastic simulation of particle transport and particle dynamics in macrophages. Quantification of F-actin resulted in an increase after incubation with PEGylated and non-PEGylated silica NPs. The small Rho-GTPases (RhoA, Rac1 and Cdc42) play a pivotal role in regulating actin dynamics. Degree of activation depended on the selection of cell species, GTPase, surface modification and concentration of NPs. Investigations had to be carried out about how far small Rho-GTPases in macrophages are able to activate NF-kB after incubation with NPs. Results of EMSAs performed with interstitial macrophages incubated with non-PEGylated silica NPs showed an increase in NF-kB activation. Investigations in the context of this work are absolutely essential for the safe handling with nanomaterials. The findings are supposed to provide assessment of toxicity and inflammatory potential of the used nanomaterials.

Originaltext vom Verlag; nicht vom SfBS bearbeitet., Störungsspezifische Interventionen ermöglichen es, Psychotherapie passgenau auf eine Störung und ihre psychopathologischen Charakteristika abzustimmen. Auf der anderen Seite erfordert Psychotherapie die Berücksichtigung individueller Lebenswirklichkeiten sowie der individuell einzigartigen Verflechtung von Lebensproblemen und Störungsgeschehen. Der in diesem Praxisleitfaden vorgestellte Ansatz einer modernen Verhaltenstherapie integriert unter dem Konzept der Therapieindividualisierung störungsspezifisches Vorgehen mit biografisch-individualisierter Therapie an den Hintergrundbedingungen. Durch die systematische Darstellung der Therapie der einzelnen Störungsbilder sowie beigefügte Checklisten ist der Praxisleitfaden insbesondere auch für Ausbildungskandidaten der Verhaltenstherapie wertvoll. Die dem Buch beigefügten Patienteninformationen ermöglichen es dem Patienten, die Therapie seiner Erkrankung entscheidend mitzugestalten.

Originaltext vom Verlag; nicht vom SfBS bearbeitet., Das Buch ist ein Begleiter für die tägliche Praxis einer zeitgemäßen Verhaltenstherapie - vom Erstkontakt mit dem Patienten über die Antragstellung im Gutachterverfahren bis zur Therapiebeendigung. Gerhard Zarbock verdeutlicht, wie biografisch-systemische Überlegungen und das Konzept der psychischen Grundbedürfnisse (Grawe) die VT in Diagnostik, Therapieplanung und -durchführung bereichern können. Das Buch bietet umsetzbare Darstellungen u.a. zu den Komplexen: Biografische Analyse, Therapieanträge, Exposition, Entspannung, Imagination, Arbeit mit Kognitionen und Emotionen, Achtsamkeit und Akzeptanz, Probleme und Krisen (z.B. Suizidalität). Fragebögen und Arbeitsblätter für Patienten runden das Buch ab.