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An update of the S3- guidelines for treatment of cardiac surgery patients in the intensive care unit, hemodynamic monitoring and cardiovascular system was published by the Association of Scientific Medical Societies in Germany (AWMF) in January 2018. This publication updates the guidelines from 2006 and 2011. The guidelines include nine sections that in addition to different methods of hemodynamic monitoring also reviews the topic of volume therapy as well as vasoactive and inotropic drugs. Furthermore, the guidelines also define the goals for cardiovascular treatment. This article describes the most important innovations of these comprehensive guidelines.

Circulating DNA released from cancerous tissues has been found to harbour tumour-associated alterations and to represent the molecular composition of the tumour. Recent advances in technologies, especially in next-generation sequencing, enable the analysis of low amounts of circulating DNA from body fluids. These “liquid biopsies” allow tumour genotyping and therapy monitoring without invasive procedures and offer the potential for early cancer detection.

Long-lasting success in lung cancer therapy using tyrosine kinase inhibitors (TKIs) is rare since the tumors develop resistance due to the occurrence of molecularly altered subclones. The aim of this study was to monitor tumors over time based on the quantity of mutant plasma DNA and to identify early indications for therapy response and tumor progression. Serial plasma samples from lung adenocarcinoma patients treated with TKIs were used to quantify EGFR and KRAS mutations in circulating DNA by digital PCR. Mutant DNA levels were compared with the courses of responses to treatment with TKIs, conventional chemotherapy, radiotherapy, or combinations thereof. Variations in plasma DNA mutation levels over time were found in 15 patients. We categorize three major courses: First, signs of therapy response are associated with a fast clearing of plasma DNA mutations within a few days. Second, periods of stable disease are accompanied by either absence of mutations or fluctuation at low levels. Finally, dramatic increase of mutational load is followed by rapid tumor progression and poor patient survival. In summary, the serial assessment of EGFR mutations in the plasma of NSCLC patients allows conclusions about controlled disease and tumor progression earlier than currently available methods.

Background.Xenon anesthesia is known to have no adverse influence on myocardial contractility and cardiocirculatory function even in cardiac compromised patients. To make use of this advantages for cardiac surgery patients undergoing extracorporeal circulation (ECC) it must be known if oxygenators are diffusible for xenon in order to avoid losses of the very expensive noble gas. Methods.Xenon saturated blood was recirculated in an in-vitroECC. In 8 experiments four common oxygenators were investigated using continuous mass spectrometry at the exhaust port to measure xenon concentrations in the exspired gas. Results.Xenon concentrations at the exhaust port of the oxygenator increased during filling the oxygenator with blood. Peak level was detected within one minute after onset of ECC. No xenon could be measured two minutes after onset of ECC. Conclusions.Using common oxygenators xenon is eliminated during ECC and lost into the atmosphere. To maintain anesthesia during ECC continuous xenon application would be necessary to compensate these losses. Due to its high price it would be too expensive to continue xenon anesthesia during ECC. Therefore it is not practicable to use the today’s oxygenators and ECC equipment in xenon anesthesia.

In most ventilators used in anaesthesia tidal volume delivered during mechanical ventilation is different from the tidal volume preset at the respirator on the basis of respirator and circuit compliance and gas compression during inspiration. The error in ventilation due to the compressed volume is especially significant clinically when the tidal volume is very small or when the airway pressure is very high. In newborns and neonates in particular, decreasing lung compliance during a surgical procedure may contribute to marked hypoventilation. We therefore investigated ventilation in newborn piglets during decreasing lung compliance induced by tension pneumothorax. We used the anaesthesia ventilator CICERO (Drager, Lubeck, Germany) and the SERVO 900 C ventilator (Siemens-Elema, Sweden). Materials and methods. Two anaesthesia ventilators, the CICERO (group I, n=8) and the SERVO ventilators (group II, n=8) were investigated following randomized selection in a group of 16 newborn piglets (Table 1). After normoventilation for 60 min a tension pneumothorax at +10 mbar was induced. After 15 min the pneumothorax was increased to +20 mbar and maintained at this level for the rest of the study. When hypercapnia (PaCO2>45 mm Hg) resulted, the respiratory rate was increased by +10/min after 15 min with pneumothorax at +20 mbar. When hypercapnia continued, the respiratory rate was increased again 25 min and if necessary also 35 min after the induction of pneumothorax at 20 mbar. After normoventilation for 60 min (T1) (Table 2), after 15 min with pneumothorax at +10 mbar (T2) and after 15 min (T3), 25 min (T4), 35 min (T5) and 45 min (T6) with pneumothorax at +20 mbar the following parameters were obtained: central venous (CVP) and mean arterial pressure (MAP), heart rate (HR), arterial (PaCO2 and end-tidal CO2 tension (PetCO2), peak inspiratory pressure (PIP), respiratory frequency (RF) and expiratory tidal (Vtex) and minute volume (VE). Results. In group I the pneumothorax resulted in a significantly smaller increase in PaCO2 (43.3±6.2 mm Hg) than in group II (Fig. 1), and hypercapnia was present in only 3 piglets. Vtex (Fig. 2), VE (Fig. 3) and PIP (Fig. 5) increased significantly, with significantly higher values than in group II, while PetCO2 (Fig. 6) decreased significantly. In group II the pneumothorax was attributed to a significant increase in PaCO2 and a marked hypercapnia in all piglets (PaCO2 61.2±5.9 mm Hg) (Fig. 1). Vtex (Fig. 2) and VE (Fig. 3) remained unchanged, while PIP (Fig. 5) and PetCO2 (Fig. 6) increased. Following the increase in RF (Fig. 4) in all piglets, Vtex and VE increased and PaCO2 and PetCO2 decreased. Conclusions. During ventilation of neonates with the SERVO ventilator a decrease in lung compliance will cause hypoventilation and hypercapnia. This is reflected by an increase in peak inspiratory pressure and can be corrected by increasing the respiratory rate. In contrast, the CICERO is able to preserve ventilation by an internal correction for gas compression, but it does not guarantee normoventilation in all cases. In neither group does the end-tidal PCO2 reflect the true ventilation during decreasing lung compliance, so that arterial blood gas analysis seems to be mandatory for the diagnosis of hypercapnia in such situations.

Background It is known that proinflammatory and anti-inflammatory cytokines are released during and after cardiopulmonary bypass (CPB) in infants and children. Sex steroids are known to have immunomodulatory functions, and release of the anti-inflammatory cytokine IL-10 is stimulated by progesterone in vitro. The purpose of the present study was to investigate the plasma levels of progesterone, IL-8 (proinflammatory cytokine) and IL-10, and to relate them to sex and postoperative morbidity.