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Practice guidelines are systematically developed statements and recommendations that assist the physicians and patients in making decisions about appropriate health care measures for specific clinical circumstances taking into account specific national health care structures. The 1st revision of the S-2k guideline of the German Sepsis Society in collaboration with 17 German medical scientific societies and one self-help group provides state-of-the-art information (results of controlled clinical trials and expert knowledge) on the effective and appropriate medical care (prevention, diagnosis, therapy and follow-up care) of critically ill patients with severe sepsis or septic shock. The guideline had been developed according to the “German Instrument for Methodological Guideline Appraisal” of the Association of the Scientific Medical Societies (AWMF). In view of the inevitable advancements in scientific knowledge and technical expertise, revisions, updates and amendments must be periodically initiated. The guideline recommendations may not be applied under all circumstances. It rests with the clinician to decide whether a certain recommendation should be adopted or not, taking into consideration the unique set of clinical facts presented in connection with each individual patient as well as the available resources.

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A case report of severe rhabdomyolysis in a 33-year-old motorcyclist after multiple trauma is described. The injuries included severe thoracic and abdominal trauma as well as injuries to the extremities and spinal column. During the first 3 days of treatment a forced volume therapy was performed because of increased levels of creatine kinase during which the patients condition stabilized both hemodynamically and respiratorily. On day 10 the patient developed a rise in temperature to 42°C with no evidence of a re-infection and the creatine kinase levels rose to 109,830 U/l. A continuous hemofiltration was started because of acute renal failure. The creatine kinase levels declined significantly and renal function also returned to normal with adequate diuresis up to day 20. After intensive questioning of the relatives a history of long-term use of anabolic steroids, clenbuterol as well as the intake of testosterone enanthate was conceded. Cocaine and amphetamines were also taken regularly by the patient. [ABSTRACT FROM AUTHOR]

Background and objective: The enzyme haeme oxygenase-1 is highly inducible by oxidative agents. Its product carbon monoxide is thought to exert anti-inflammatory properties. We recently showed, that critically ill patients produce higher amounts of carbon monoxide compared to healthy controls. In the present study we compare endogenous carbon monoxide production with the severity of illness of intensive care unit patients. Methods: Exhaled carbon monoxide concentration was measured in 95 mechanically ventilated, critically ill patients (mean age ± SD, 59.5 ± 15.7) on a carbon monoxide monitor. Measurements were taken every hour for 24 h in each patient. Data were analysed using Mann-Whitney rank sum test. Correlation analysis was performed with the Spearman's rank order correlation. Results: Carbon monoxide production correlated weakly with the multiple organ dysfunction score (R = 0.27; P 0.009). Patients suffering from cardiac disease (median 22.5, interquartile range 16.2#x2013;27.4 μL kg-1 h-1,vs. median 18.2, interquartile range 14.2#x2013;21.8 μL kg-1 h-1, P = 0.008) and critically ill patients undergoing dialysis (median 25.0, interquartile range 21.4#x2013;30.2 μL kg-1 h-1, vs. median 19.4, interquartile range 14.7#x2013;23.3 μL kg-1 h-1, P = 0.004) produced significantly higher amounts of carbon monoxide compared to critically ill controls. Conclusion: The findings suggest that endogenous carbon monoxide production might reflect the severity of acute organ dysfunction. [ABSTRACT FROM AUTHOR]

Vasopressin and terlipressin are increasingly used as alternative non-adrenergic vasopressors for hemodynamic support of septic patients with arterial hypotension. Despite excellent vasopressive effects, vasopressin analogues may potentially impair macro-hemodynamics, oxygen transport and microvascular blood flow. Due to those unwanted side-effects, vasopressin and terlipressin may potentially compromise organ function and possibly foster the development of multiple organ failure. This review article discusses the results of clinical and experimental studies to judge the effects of vasopressin and terlipressin on microcirculation, oxygen supply, metabolism and organ function in patients with sepsis or systemic inflammatory response syndrome (SIRS). Although vasopressin analogues are emerging as promising alternatives to treat catecholamine-refractory hypotension, there is no evidence that vasopressin receptor agonists improve outcome. To date, vasopressin and terlipressin can, therefore, not be recommended for routine clinical use. [ABSTRACT FROM AUTHOR]

Background and objective: Since the moribund hypodynamic phase of septic shock has primarily been studied in small animal models, the objective of this study was to investigate the usefulness of infusing Salmonella typhosa endotoxin at incrementing doses to establish an ovine model of hypoclynamic endotoxaemia. Methods: In a prospective laboratory experiment, eight adult ewes were instrumented (or a chronic study. Following a baseline measurement in the healthy state, a continuous endotoxin infusion was started with 10 ng kg-1 min-1 and was doubled every hour seven times. Haemodynamics, key variables of oxygen transport, and arterial lactate concentrations were determined every hour. Results: In a dose-dependent manner, endotoxin infusion caused pulmonary hypertension, decreased cardiac output and mean arterial pressure, increased heart rate, and to a certain extent, systemic vascular resistance index. Following 4 h of endotoxaemia, the maximum decrease in cardiac output occurred (4.8 ± 0.2 vs. 7.6 ± 0.3 L min-1 P <0.001). This was accompanied by tissue dysoxia, represented by decreases in oxygen delivery (797 ± 20 vs. 1041 ± 28 mL min-1), oxygen consumption (277 ± 14 vs. 396 ± 15 mL min-1) and oxygen extraction rate (0.35 ± 0.01 vs. 0.38 ± 0.01%; each P < 0.01), as well as an increase in arterial lactate concentration (1.7 ± 0.1 vs. 0.7 ± 0.1 mmol L-1; P<0.05). Conclusions: This large animal model may be helpful to study the pathophysiology responsible (or cardiovascular failure, and also new therapeutic approaches relevant to management of hypodynamic circulation in the common setting of progressed systemic inflammation. [ABSTRACT FROM AUTHOR]

The possible beneficial effect of supplemental glutamine (Gln) in critically ill patients has been suggested to be mediated by the induction of the cytoprotective heat shock proteins (HSP)32 and HSP72. There is evidence that HSP72 and HSP32 have opposite effects on the hemodynamic situation during endotoxemia. Therefore, the effect of Gln supplementation on the cardiovascular system is not clear. We investigated the effect of alanyl-Gln (Ala-Gln) dipeptide on cardiovascular function in healthy and endotoxemic sheep. Ten sheep catheterized for chronic studies received Ala-Gln 700 mg/(kg x d) [equal to 470 mg/(kg x d)Gln] on 4 consecutive days, and 10 sheep received NaCl (9 g/L) as the control solution. On d 4, four sheep of each group were killed and myocardial samples were taken for immunohistochemistry. The remaining sheep received a continuous infusion of endotoxin [Salmonella typhosa, 10 ng/(kg x min)]. Hemodynamic parameters were measured before application of Ala-Gln or the control solution, and during endotoxemia. Myocardial HSP72 immunoreactivity was determined by immunohistochemistry. After 24 h of endotoxemia, the sheep exhibited a hyperdynamic circulation. No difference was found in the hemodynamic parameters between treatment and control group. Ala-Gln treated sheep had a greater increase in myocardial HSP72 immunoreactivity compared with controls after (P < 0.05) but not before endotoxemia. In summary, Ala-Gln increased HSP72 immunoreactivity after endotoxemia, but did not alter hemodynamic parameters. Thus, Ala-Gln supplementation does not seem to aggravate the hyperdynamic circulation in endotoxemic shock. [ABSTRACT FROM AUTHOR]

Comments on a study on the effects of hydroxyethyl starch on blood coagulation. Interpretation of the clinical results; How the effects on coagulation may be determined.

Background: Surgery is the usual therapy for patients with primary hyperparathyroidism. We investigated the ability of a calcimimetic drug that inhibits parathyroid hormone secretion in vitro to decrease serum parathyroid hormone and calcium concentrations in patients with this disorder.Methods: We performed a randomized, placebo-controlled study of single oral doses of 4 to 160 mg of the calcium-receptor agonist drug R-568 in 20 postmenopausal women with mild primary hyperparathyroidism. At base line, the mean (+/-SE) serum calcium concentration was 10.7+/-0.2 mg per deciliter (2.67+/-0.05 mmol per liter). Serum parathyroid hormone and calcium were measured repeatedly after each dose, and safety was assessed.Results: Administration of R-568 resulted in a dose-dependent inhibition of parathyroid hormone secretion. The mean serum parathyroid hormone concentration, which was 77+/-11 pg per milliliter (18.8+/-2.7 pmol per liter; normal range, 16 to 65 pg per milliliter [3.9 to 15.9 pmol per liter) at base line, fell by 26+/-8 percent after 20 mg of R-568 (P=0.03), by 42+/-7 percent after 80 mg (P = 0.01), and by 51+/-5 percent after 160 mg (P=0.005). Serum ionized calcium concentrations fell only after the 160-mg dose, with the decrease closely following the decrease in the serum parathyroid hormone concentration.Conclusions: The calcimimetic drug R-568 reduces serum parathyroid hormone and ionized calcium concentrations in postmenopausal women with primary hyperparathyroidism. [ABSTRACT FROM AUTHOR]