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Es existieren bislang keine Untersuchungen zu Belastungen fur Patienten der Intensivstation, die sowohl das Belastungsempfinden als auch die erlebte Kontrollierbarkeit erfassen. Mit dieser Untersuchung sollten die Fragen beantwortet werden, welche Situationen von Patienten der Intensivstation als belastend erlebt werden, ob diese aus Patientensicht kontrollierbar sind, und ob das Belastungserleben von der Kontrollierbarkeit abhangig ist. Es wurde ein Fragebogen zu 18 potenziell belastenden Situationen fur Patienten der Intensivstation konzipiert. Diese sollten hinsichtlich ihres Vorkommens, der Wiederholungshaufigkeit, der Belastung und des Kontrollempfindens beurteilt werden. 198 Patienten der chirurgischen Intensivstation und 100 Patienten der allgemeinchirurgischen Normalstation wurden wahrend ihres stationaren Aufenthalts befragt. Patienten der Intensivstation erinnerten signifikant mehr Belastungssituationen als die der Normalstation (M ± SD = 10,2 ± 2,7 vs. 6,6 ± 2,0; d = 1,48; p

Beim septischen Schock sollten vasokonstriktorische und positiv inotrope Substanzen moglichst erst dann eingesetzt werden, wenn sich Blutdruck und Organperfusion trotz Vorlastoptimierung nicht adaquat verbessern lassen. Der zunehmende Einsatz des hamodynamischen Monitorings hat gezeigt, dass in einigen Fallen bei initial unzureichender Volumensubstitution hoch dosierte Katecholamine Verwendung finden. Ziel der Studie ist zu zeigen, dass es in einigen Fallen moglich ist, durch eine dem Bedarf entsprechende Volumensubstitution verbunden mit einer gezielten Reduktion der Katecholamindosis deren Bedarf zu reduzieren. In einer retrospektiven Beobachtungsstudie wurden 29 Patienten einer chirurgischen Intensivstation (17 mannlich, 12 weiblich; mittleres Alter ± Standardfehler: 71 ± 10 Jahre) mit septischem Schock analysiert, die hoch dosiert Katecholamine erhielten (Noradrenalin 0,204; Dobutamin 3,876; Adrenalin 0,025 µg/kgKG/min im Median; bis zu 0,810/22,222/0,407 µg/kgKG/min; 28/20/17 Patienten). Die Extremitaten waren initial bei allen Patienten kuhl und marmoriert, wahrend der mittlere arterielle Druck ≥ 65 mmHg war. Der mediane zentrale Venendruck betrug 17 mmHg (5–34 mmHg), der Laktatspiegel 2,78 mmol/l (0,93–10,67 mmol/l). Das Standardtherapiekonzept umfasste eine forcierte, dem Bedarf entsprechende Volumensubstitution, kombiniert mit einer aktiven Reduktion vasokonstriktorischer und positiv inotroper Substanzen, deren Ausmas mithilfe eines Autotransfusionsmanovers, klinischer Zeichen und in 19 Fallen mithilfe eines hamodynamischen Monitorings gesteuert wurde (Pulmonaliskatheter, Vigilance II™: n = 10; FloTrac, Vigileo™: n = 9, davon PreSpep™: n = 5, Edwards Lifesciences). Der Volumenbelastungstest wurde bei Wiedererwarmung der Extremitaten, ansteigenden Diuresemengen und fehlender Reaktion auf das Autotransfusionsmanover beendet. Die mittlere Katecholamindosis lies sich bei allen Patienten signifikant reduzieren: Noradrenalin 0, Dobutamin 1,852, Adrenalin 0 µg/kgKG/min (bis zu 0,133/6,289/0,091 µg/kgKG/min; p

The aim of this study was to evaluate the efficacy of sustained release of vancomycin and teicoplanin from a resorbable gelatin glycerol sponge, in order to establish a new delivery system for local anti-infective therapy.60 plasticized glycerol gelatin sponges containing either 10 or 20% gelatin (w/v) were incubated in vancomycin or teicoplanin solution at 20 degrees C for either 1 or 24 h. In vitro release properties of the sponges were investigated over a period of 1 week by determining the levels of vancomycin and teicoplanin eluted in plasma using fluorescent polarization immunoassay. The rate constant and the half-life for the antibiotic release of each group were calculated by linear regression assuming first order kinetics.Presoaking for 24 h was associated with a significant increase in the total antibiotic release in all groups opposed to 1 h of incubation, except for the 10% sponges presoaked in teicoplanin. Doubling the gelatin content of the sponges from 10 to 20% significantly increased the total release of antibiotic load only in teicoplanin-containing sponges after 24 h incubation. In all corresponding groups investigated, release of vancomycin was more prolonged compared to teicoplanin, which allowed a gradual release beyond 5 days. The half-life (h +/- SEM) of both types of vancomycin-containing sponges was significantly prolonged by 24 h incubation in comparison to 1 h incubation (29.1 +/- 5.9 vs 5.9 +/- 1.0; p0.001, 30.0 +/- 2.1 vs 11.1 +/- 1.9; p0.001). However, neither doubling the gelatin content of the sponges nor a prolonged incubation was associated with a significantly prolonged delivery of teicoplanin.This study demonstrated a better diffusion-controlled release of vancomycin-impregnated glycerol gelatin sponges compared to those pretreated with teicoplanin. The plasticized glycerol gelatin sponge may be a promising carrier for the application of vancomycin to infected wounds for local anti-infective therapy.

Bleeding in the tracheobronchial tree in intubated patients on an intensive care unit is a potentially life-threatening incident. The antecedent state of disease and frequent respiratory failure require immediate and effective therapeutic measures to avoid further respiratory and cardiocirculatory depression. We present our bronchoscopic management of endobronchial bleeding. Cardiorespiratory function must be maintained by modification of the mechanical ventilation and drug therapy owing to the patient's condition. Seven consecutive patients with acute endobronchial bleeding were treated with fiberoptic bronchoscopy and instillation of cold epinephrine-saline solution (1:10,000-100,000) during the period of July 1997 to December 1997. Control of bleeding was achieved after 1 to 20 (mean +/- SEM: 5.86 +/- 0.93) bronchoscopic interventions during a period of 0.5 hours to 10 days. One control bronchoscopy was performed additionally in every patient. Cardiocirculatory instability was observed in five patients. Six patients survived; one patient died of uncontrolled bleeding caused by severe pulmonary aspergillosis. Fiberoptic endobronchial epinephrine instillation is an effective therapy for life-threatening hemoptysis in critically ill patients. Widespread use of flexible bronchoscopy makes this procedure immediately applicable in critical situations. Intubated and mechanically ventilated patients with life-threatening hemoptysis especially benefit from this rapidly feasible procedure.

Evolution of hemodynamic monitoring revealed many septic shock patients on high catecholamines without proper fluid loading before. The aim of our study was to show that it is possible in quite a few cases to reduce these agents by a forced volume resuscitation combined with active reduction of catecholamines.

In acute respiratory failure (ARF), in particular acute lung injury (ALI) and respiratory distress syndrome (ARDS), an intervention in the form of rotational therapy (RT) or the prone position (PP) may improve oxygenation by recruiting alveoli situated in dorsal-dependent regions and by alteration of the ventilation/perfusion ratio. The efficacy of this interventions can be demonstrated among other parameters by the course of the oxygenation index. The aim of our study is to analyze the prognostic value of the course of the oxygenation index before and after such an intervention.

In acute respiratory failure (ARF), in particular acute lung injury (ALI) and respiratory distress syndrome (ARDS), change from the supine position (SP) to the prone position (PP) or the use of kinetic therapy can improve oxygenation by recruiting alveoli situated in dorsal-dependent regions of the lung and by alteration of the ventilation/perfusion ratio. The efficacy of this intervention can be demonstrated by the course of oxygenation index. The aim of our study is to compare prone position ventilation (PP) and kinetic therapy (KT) in the first 5 days after intervention in patients with acute respiratory failure.

In acute respiratory failure, classified as acute lung injury (ALI) or the more severe acute respiratory distress syndrome (ARDS), prone position ventilation (PPV) can improve oxygenation by recruiting alveoli situated in dorsal-dependent regions of the lung and by alteration of the ventilation/perfusion ratio. The aim of our study is to analyze the prognostic value of the change of oxygenation after starting prone position ventilation in ARF.

In acute respiratory failure (ARF), in particular acute lung injury (ALI) and respiratory distress syndrome (ARDS), change from supine (SP) to prone position (PP) can improve oxygenation. The efficacy of this intervention can be demonstrated by the course of oxygenation index. Nevertheless prone position ventilation (PPV) showed no improvement in survival so far. Endpoint for the assessment of therapeutic effects of an intervention like PPV is generally the mortality rate. The aim of our study is to attempt to analyze the discrepancy between positive effects of prone position ventilation on oxygenation index in ARF and the comparatively high mortality rates despite of this intervention. We studied 110 consecutive patients with ALI (n = 18) and ARDS (n = 92) at mean age 66 ± 13 [SE] years in a clinical follow-up design at a surgical ICU in a university hospital, who met the criteria of the American European consensus definition. All patients were ventilated intermittent in SP and in PP (135° left/right-side-position) for at least 6 hours/day. Data collection included apart from baseline characteristics individual oxygenation index and underlying diseases of the patients, in particular if of benign or malignant nature. We compared individual oxygenation index (PaO2/FiO2) before and after start of prone position (SPSS® T-test) and the data set of each patient with outcome. PPV was well tolerated in all n = 110 patients and showed an significant increase of PaO2/FiO2 in n = 106 within the first 6 hours (SP 149 ± 0.52 vs PP 230 ± 0.73 mmHg [mean ± SEM]). In the remaining four cases there was a positive effect within the first 24 hours. Sixty-seven (61%) of the patients died in the course of intensive care therapy and 43(39%) survived. Seven died with an oxygenation index below 100, another 36 with a ratio below 200, 17 below 300 and seven above 300 mmHg. Patients with a malignant underlying disease as cofactor had a 1.8 times higher and those with sepsis a 3.15 times higher risk to die during their ICU-stay despite of PPV. Despite of positive effects of PPV on oxygenation in our patients a considerable part of them died. To our amazement oxygenation index previous to death was not the main problem for most part of the patients in that phase. Malignant diseases in history and sepsis during the ICU-stay seem to increase the risk to die in the course of ALI or ARDS regardless the use of PPV conspicuously. Our results show that for the assessment of a therapeutic intervention in acute respiratory failure not only mortality as an endpoint seems to be suitable, but also important clinical cofactors.

Bleeding into the tracheobronchial tree is a potentially fatal occurrence for intubated patients. The subsequent acute respiratory failure requires an effective therapy. Fiberoptic bronchoscopy represents an easy available technique for the diagnosis and treatment of this type of hemoptysis.