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A growing number of patients with increasingly complex or specialized diseases are being treated in hospitals worldwide. The treatment requirements of some of these patients are exceeding the capacity of standard nursing units. However, the severity of these diseases or the treatment requirements for these specific clinical pictures do not always justify admission to an intensive care unit. For this reason, an increasing number of special units (intermediate care units) are being set up to offer highly specialized treatment and close monitoring, in order to fulfil an intermediate role between the standard care unit and the intensive care unit. The recommendations of the German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI) on the personnel, capacity, equipment and structure of these units are intended to provide the framework for the setting up and operation of intermediate care units in collaboration with experts on both an evidence-based and an expert-based basis (where scientific evidence is not available). Where only minimal or indirect evidence is available, patient safety is paramount in the formulation of the recommendation.

Hintergrund: Die Endpunkte der Volumentherapie bei schwerer Sepsis und septischem Schock sind nicht selten Gegenstand kontroverser Diskussionen am Krankenbett. Methode: Anhand der Leitlinien und der aktuellen Literatur werden die Zielparameter sowie die durch Volumentherapie erreichbaren Wirkungen und Nebenwirkungen vorgestellt. Ergebnisse: Werden die Zielparameter der Volumentherapie in der Sepsis nicht in den ersten 6 h erreicht, ist ein erweitertes hämodynamisches Monitoring zur Überwachung der Vorlast und der Volumenreagibilität sowie der Gewebsoxygenierung indiziert. Eine Überinfusion führt nicht selten zu grotesken Anasarka und Nebenwirkungen am Herz, an der Lunge und im Abdomen, die lebensbedrohliche Ausmaße annehmen können. Schlussfolgerung: Die Grenzen der Volumentherapie sind nicht nur in hämodynamischen Zielparametern zu sehen, sondern auch in den Nebenwirkungen der Volumentherapie, die im Rahmen der Sepsisbehandlung nicht sämtlich vermieden, aber in ihren Auswirkungen begrenzt werden können.

Nach chirurgischer Homoostasestorung kommt es durch hormonelle sowie immunologische Veranderungen regelhaft zu charakteristischen passageren Stoffwechselveranderungen (Hyperglykamie, Eiweiskatabolie)

Cytomegalovirus (CMV) infection is an important cause of disease in immunocompromised patients. In a prospective longitudinal study of 34 septic patients, the incidence of active CMV infection was examined. Eleven of 34 patients (32.4%) had active CMV infection, diagnosed by immunocytochemical staining of CMV pp65 antigen in blood leukocytes and/or detection of CMV DNA by PCR. Positive results for CMV infection were obtained in a median of 4 days (by PCR) or 11 days (by staining of pp65 antigen) after onset of sepsis. Twenty patients for whom more than one sample was examined were selected for further analysis. Among the patients with active CMV infection (nine of 20) there was a trend toward higher median values of tumor necrosis factor alpha, interleukin-1 beta, alanine aminotransferase, and aspartate aminotransferase in plasma, in comparison with the values for patients without CMV infection. Sepsis in patients with CMV infection may affect outcome of the disease.

Fellermann: Ein singularer Parameter ist meines Erachtens nicht verfugbar. Fur jedwedes Eingriffsverfahren gilt, dass diverse hamodynamische und laborchemische Kenngrosen auf eine Sanierung hindeuten, so z.B. ein Schwinden der SIRS (systemisches inflammatorisches Response-Syndrom)-Kriterien. Hier ist in erster Linie arztliche Beurteilung und Gewichtung gefragt. Bezuglich endoskopisch durchgefuhrter Drainagen oder Nekrosektomien ist auch der lokale Eindruck nicht zu unterschatzen. Eine Einschatzung gemas irgendwelcher Scoring-Systeme, sei es auch sepsisadaptiert, ist im klinischen Gebrauch viel zu sperrig und wenig hilfreich. Allenfalls lasst sich damit die Mortalitat prognostizieren (APACHE II, MPI).

Grose viszeralchirurgische Eingriffe sind nicht nur eine Herausforderung fur den Chirurgen als Operateur, sondern auch fur den Chirurgen als perioperativ tatigen Arzt und fur den operativen Intensivmediziner. Die Erweiterung der operationstechnischen Moglichkeiten zur Minimierung des operativen Traumas (minimal invasive Chirurgie) und die Entwicklung in der Intensivmedizin in den letzten Jahren haben Operationen ermoglicht, die vor mehr als zehn Jahren noch undenkbar waren. So kommen immer komplexer vorerkrankte und immer altere Patienten zu immer komplexeren Eingriffen in unsere Kliniken. Zur perioperativen Medizin in der Viszeralchirurgie (und auch in allen anderen chirurgischen Gebieten) gehoren neben der praoperativen Risikoabschatzung, der Patientenkonditionierung und -vorbereitung sowie der differenzierten Indikationsstellung auch die postoperative Uberwachung, Komplikationsvermeidungsstrategien und das Komplikationsmanagement. Sie beinhaltet unter anderem Schmerztherapie, Ernahrungstherapie, Therapie der Sepsis, Volumenmanagement, Antibiotikatherapie, Gerinnungsmanagement und Thromboseprophylaxe, aber auch die Berucksichtigung diverser – meist internistischer – Begleiterkrankungen und zudem eingriffsspezifische Behandlungskonzepte. Einige dieser Themen werden im vorliegenden Heft zur perioperativen Medizin viszeralchirurgischer Eingriffe behandelt. Die perioperative Medizin leistet einen zunehmend wichtigen Beitrag in der Behandlung chirurgischer Patienten – praoperativ auf den normalen Pflegestationen, postoperativ auch auf den Intensivstationen. Der Chirurg muss die Herausforderungen der perioperativen Medizin annehmen. Wenn wir als Chirurgen dieses Arbeitsfeld nicht kompetent besetzen, werden es andere tun (mussen). Die obligatorische sechsmonatige Weiterbildung in der Intensivmedizin im Rahmen der Weiterbildung in einem chirurgischen Fach dient unter anderem auch dazu, Arzte fur dieses Tatigkeitsfeld fit zu machen. Ob diese Weiterbildungszeit dafur ausreicht, erscheint allerdings fraglich angesichts der Komplexitat der perioperativen Probleme unserer Patienten. Eine Veranderung der Weiterbildungsstruktur sollte in den Fachgesellschaften und Berufsverbanden sowie in den Arztekammern diskutiert und angegangen werden: Nur wenige Chirurgen absolvieren die zweijahrige Zusatzweiterbildung «Intensivmedizin», auch weil Karriereperspektiven fehlen und die Arbeitsbedingungen durch Schichtdienst und Personalmangel wenig attraktiv sind. Die Chirurgie hat ein Nachwuchsproblem, die chirurgische Intensivmedizin noch viel mehr – und zum Teil auch die Intensivmedizin in anderen Fachern. Ein Losungsansatz konnte die Umwandlung der Zusatzweiterbildung «Intensivmedizin» in einen Schwerpunkt Intensivmedizin in den Fachern Anasthesiologie, Chirurgie, Innere Medizin, Kinderund Jugendmedizin und Neurologie/Neurochirurgie sein. Als weiterer Baustein innerhalb der Weiterbildungsmoglichkeiten ist eine neue Zusatzweiterbildung «Perioperative Medizin» denkbar fur alle chirurgischen Fachgebiete mit Zugang zur Weiterbildung «Intensivmedizin» (also fur Allgemeinund Viszeralchirurgie, Herzund Gefaschirurgie, Thoraxchirurgie, Unfallchirurgie, Neurochirurgie und Plastische Chirurgie/Verbrennungsmedizin). Fur den Erwerb einer solchen Zusatzweiterbildung sollte eine mindestens einjahrige intensivmedizinische Weiterbildung Voraussetzung sein. Die Weiterbildung sollte fokussiert sein auf die Versorgung von chirurgischen Patienten auf der Normalstation, auf ihre metabolischen, internistischen, kardiologischen, pulmonologischen und neurologischen Begleiterkrankungen, Ernahrung, Schmerztherapie und auf adjuvante medikamentose Therapien im perioperativen Kontext. Die so weitergebilde

A rare case of hibernoma about the nipple in a 9-year-old boy is presented: the tumour was peculiar not only for the age and region, but also for its superficial, subepidermal site.

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.

The first report of multiresistant Acinetobacter baumanii (MRAB) was published in 1994. We report about an outbreak sensitive to Polimyxin only. In June 2006 a German holidaymaker (male, 70 years old; patient 1) in Greece felt dyspnea, thoracic pain and fever. He went to a hospital in Crete. CT indicated left-sided pleural empyema, mediastinal emphysema, pericardial effusion and pneumonia. Rapid deterioration lead to septic shock with need for mechanical ventilation. He came to our ICU (15 beds and six IMC beds) via air transport. Endoscopy showed esophagus perforation with need for operation and endoscopic stenting. Several BALs and a central venous catheter from the beginning showed MRAB with intermediate susceptibility to meropenem/aminoglycosides only. The patient received meropenem and gentamycin at first. Despite isolation, MRAB spread over and infected eight more patients in separate rooms and different sections of the ICU 32 days later. Further transmission occurred within a few days: three male patients with multiple trauma (42, 20, and 62 years old; patients 2, 3, and 4), cardia carcinoma (female, 66 years old; patient 5), necrotizing pancreatitis (female, 78 years old; patient 6), splenomegaly owing to polycythaemia vera (male, 74 years old; patient 7 – MRAB diagnosis postmortem), rectal carcinoma (female, 76 years old; patient 8 – isolation because of MRSA infection even before) and respiratory failure after gastric banding (female, 41 years; patient 9). All patients suffered from septic shock with high fever, needed high volume replacement and catecholamines several times and prolonged mechanical ventilation. MRAB was isolated in the tracheal secretion or BAL in all patients, in abdominal drainage (patient 6), and in central venous catheter (patient 5). Environmental investigations showed no problematic circumstances. Colistin i.v. is not available in Germany so it had to be procured from the USA, which caused a delay of treatment for a few days. Another delay occurred because of the rapid growing number of patients who needed Colistin. Patients were treated with an adjusted dosage for 16 days. All patients of the ICU were isolated to avoid new infections as a precaution. After convalescence of two patients, all MRAB patients were moved to the IMC, which was converted to an ICU for this period, to isolate infected patients from uninfected. Three out of nine patients died. All these laborious measures with a great expenditure of logistics worked well; no further transmissions were observed.

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.

Tolerance for mechanical ventilation is generally achieved by continuous application of analgesics and sedatives. Their effect is usually controlled by physical examination. The dosage in daily routine occasionally is not adapted to the patients needs in the circardian course. Evidence exists that classical neurological and hemodynamic parameters do not always reflect the level of sedoanalgesia. Neuromonitoring with heart-rate-variability (HRV) is a new opportunity to evaluate the patients neurological status. HRV is a window for usually invisible central autonomic regulation. This phenomenon is caused by oscillation in the interval between consecutive heart beats. It represents a quantitative marker of autonomic activity. Currently monitoring of autonomic nervous system is no routine tool for mechanically ventilated patients. Our study presents first results of continous neuromonitoring of autonomic nervous system with heart-rate-variability in the setting of an intensive care unit.

In acute respiratory distress syndrome (ARDS) change from supine (SP) to prone position can improve gas exchange by recruiting alveoli situated in dorsal dependent regions and by alteration of ventilation/perfusion ratio. The aim of this study was to investigate the effect of prone position (PP) after application of high fractional inspired oxygen (hFiO2), inverse ratio ventilation (IRV), positive end exspiratory pressure (PEEP)as well as kinetic therapy (KT) and hemofiltration (HF) did not lead to a breakthrough in treatment of severe ARDS.

Acid-base imbalances are an important aspect while using continuous renal replacement techniques in critically ill patients. The quality of replacement fluid needs to be considered regarding to the acid-base requirements especially in septic patients. Commonly used replacement fluids contain lactate as buffer. Whereas lactate has to enter the Cori- or Citrate-Cycle to become effective as a buffer, bicarbonate can act immediately. The metabolism of lactate in addition is depending on the impaired liver function of patients with septic shock and represents an oxygen consuming process.

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.