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Successful smoking cessation is associated with a survival benefit for patients with lung cancer. However, smokers newly diagnosed with non-small cell lung cancer and scheduled for curative resection are frequently discouraged from stopping smoking in the immediate preoperative period. This recommendation is based on the results of one single prospective cohort study published in 1998 which reported an increased risk of perioperative pulmonary complications in patients undergoing non-thoracic surgery who had reduced their tobacco consumption within the two months leading up to the operation. During the past 12 years, numerous observational studies have investigated the impact of preoperative smoking cessation on perioperative risk for thoracic and non-thoracic surgery. However, no more than six studies included patients with pulmonary neoplasms. Owing to methodological limitations and considerable heterogeneity of the included patient groups, the existing data are insufficient to support or refuse any recommendation regarding cessation advice for patients during the immediate preoperative phase. In view of the post-cessation recovery time-course of pathophysiological alterations relevant to the occurrence of perioperative complications, a smoke-free preoperative interval of 2 - 6 weeks appears most favourable. However, this is difficult to achieve as a curative resection should not be postponed. Since there is no scientific evidence demonstrating a negative impact of preoperative smoking cessation on prognosis, patients newly diagnosed with lung cancer should be encouraged to make an attempt to quit while waiting for thoracic surgery.

Eine Pneumonie, die nach mehr als 48-stundiger maschineller Beatmung entsteht, wird als ventilatorassoziierte Pneumonie (VAP) bezeichnet. Die VAP ist die haufigste nosokomiale Infektion in der Intensivmedizin und mit einer langeren Intensivstations-, Krankenhausverweildauer und einer erhohten Letalitat verbunden. Der zentrale Pathomechanismus fur die Pneumonieentstehung ist weniger die maschinelle Beatmung als vielmehr der Keimeintritt in das Tracheobronchialsystem der Lungen uber den Endotrachealtubus. Vermeidung der endotrachealen Intubation, Hygienemasnahmen, Reduktion der oropharyngealen Keimlast und Vermeidung bzw. Reduktion der Mikroaspiration sind wesentliche Ansatzpunkte von Praventionsstrategien. Der therapeutische Erfolg bei der Behandlung einer VAP ist an eine fruhzeitige Diagnose und Therapie gebunden. Der Verdacht auf eine Pneumonie wird nach klinischen und radiologischen Kriterien gestellt. Biomarker und mikrobiologische Befunde sind fur die Verlaufsbeurteilung und Reevaluierung der Verdachtsdiagnose unentbehrlich.

Patienten mit soliden Tumoren und hamatologischen Neoplasien konnen fur den Anasthesisten mit seinen vielschichtigen Kernkompetenzen (Narkosefuhrung, Intensiv-/Notfallmedizin, Schmerztherapie und Palliativmedizin) eine besondere Herausforderung darstellen, die u. a. auf systemische Krankheitsmanifestationen, insbesondere in metastasierten Stadien, auf komplexe Folgewirkungen toxischer onkologischer Therapien, insbesondere in kurativ intendierten Behandlungskonzepten, auf schwierige ethische Entscheidungsfindungen, insbesondere in Akutsituationen, und auf die besondere emotionale Situation des Patienten, die sich durch den gesamten Erkrankungsverlauf hindurchziehen kann, zuruckzufuhren ist. Hinzu kommt eine Vielzahl neuer Entwicklungen in der modernen Onkologie, die diese Besonderheiten onkologischer Patienten erschweren und direkten Einfluss auf anasthesiologisches Tun haben konnen und daher im Folgenden dargestellt werden.

Worldwide, sepsis is one of the leading causes of morbidity and mortality. In Germany about 79,000 (116/100,000) suffer from sepsis, and the incidence of severe sepsis and septic shock is about 75,000 cases per year. Patients are at high risk for irreversible organ failure and a lethal course. About 60,000 die from sepsis annually, and survivors have a reduced quality of life. It is presumed that demographic changes will lead to an increased incidence and overall mortality in the future. Additionally sepsis imposes a considerable economic burden to the society. Early and comprehensive treatment significantly improves outcome. An increased knowledge and awareness about the epidemiology, definitions and therapy of sepsis might contribute to the improved outcome. This review aims to present information on current definitions, epidemiology and the economic burden of sepsis.

Die elektrische Impedanztomographie (EIT) ist ein nichtinvasives, strahlungsfreies, funktionelles Bildgebungsverfahren, das moglicherweise eine Bedeutung in der bettseitigen und kontinuierlichen Uberwachung der regionalen Ventilation erlangen wird. Das Prinzip basiert auf der Einspeisung kleiner Wechselstrome uber Oberflachenelektroden, die am Umfang des Thorax angebracht sind und der nachfolgenden Messung von Oberflachenspannungen. Die gemessenen Oberflachenspannungen hangen von der Impedanz-(Widerstands)verteilung innerhalb des Thorax ab. Der gemessene Widerstand wird zum uberwiegenden Teil durch den intrapulmonalen Luftgehalt bestimmt. Aufgrund der hohen zeitlichen Auflosung bietet das Verfahren die Moglichkeit schnelle physiologische Veranderungen zu erfassen. Seit uber 20 Jahren erfreut sich die EIT einer steigenden Beachtung uberwiegend fur wissenschaftliche Fragestellungen. Einen Einzug in die klinische Routine zur Uberwachung der regionalen Lungenfunktion hat sie jedoch bisher nicht gefunden. Diese Ubersicht beschreibt den derzeitigen Stand der EIT, ihre Moglichkeiten und Einschrankungen.

After analyzing the existing documentation protocol for the emergency room (ER), the department of anesthesiology of the Medical University of Göttingen (UMG) developed a new department-specific ER protocol.The objective was to improve the flow of patient information from the preclinical situation through the emergency room to the early inpatient period. With this in mind a new emergency protocol was developed that encompasses the very heterogeneic patient collective in the ER as well as forming a basis for quality management and scientific investigation, taking user friendliness and efficiency into consideration.A strategical development of a new emergency room protocol is represented, which was realized using a self-developed 8-step approach. Technical support and realization was carried out using the Scribus 1.4.2 open source desktop and GIMP 2.8.4 GNU image manipulation graphic programs.The new emergency room protocol was developed based on scientific knowledge and defined targets. The following 13 sections represent the contents of the new protocol: general characteristics, emergency event, initial findings and interventions, vital parameters, injury pattern, vascular access, hemodynamics, hemogram/blood gas analysis (BGA), coagulopathy, diagnostics, emergency interventions, termination of ER treatment and final evaluation.The structured and elaborated documentation was limited to the target of two sides and succeeds in incorporating trauma patients as well as non-trauma patients in the ER.

A recent survey conducted by the publicly funded Competence Network Sepsis (Sep-Net) reveals that severe sepsis and/or septic shock occurs in 75,000 inhabitants (110 out of 100,000) and sepsis in 79,000 inhabitants (116 out of 100,000) in Germany annually. This illness is responsible for approx. 60,000 deaths and ranges as the third most frequent cause of death after acute myocardial infarction. Direct costs for the intensive care of patients with severe sepsis alone amount to approx. 1.77 billion euros, which means that about 30% of the budget in intensive care is used to treat severe sepsis. However, until now German guidelines for the diagnosis and therapy of severe sepsis did not exist. Therefore, the German Sepsis Society initiated the development of guidelines which are based on international recommendations by the International Sepsis Forum (ISF) and the Surviving Sepsis Campaign (SSC) and take into account the structure and organisation of the German health care system. Priority was given to the following guideline topics: a) diagnosis, b) prevention, c) causative therapy, d) supportive therapy, e) adjunctive therapy. The guidelines development process was carefully planned and strictly adhered to according to the requirements of the Working Group of Scientific Medical Societies (AWMF).

A recent survey conducted by the publicly funded Competence Network Sepsis (SepNet) reveals that severe sepsis and/or septic shock occurs in 75,000 inhabitants (110 out of 100,000) and sepsis in 79,000 inhabitants (116 out of 100,000) in Germany annually. This illness is responsible for approximately 60,000 deaths and ranges as the third most frequent cause of death after acute myocardial infarction. Direct costs for the intensive care of patients with severe sepsis alone amount to approximately 1.77 billion euros, which means that about 30% of the budget in intensive care is used to treat severe sepsis. However, until now German guidelines for the diagnosis and therapy of severe sepsis did not exist. Therefore, the German Sepsis Society initiated the development of guidelines which are based on international recommendations by the International Sepsis Forum (ISF) and the Surviving Sepsis Campaign (SSC) and take into account the structure and organization of the German health care system. Priority was given to the following guideline topics: a) diagnosis, b) prevention, c) causative therapy, d) supportive therapy, e) adjunctive therapy. The guidelines development process was carefully planned and strictly adhered to the requirements of the Working Group of Scientific Medical Societies (AWMF).

Zusammenfassung Trotz anhaltender Diskussion ist die extrakorporale Membranoxygenierung (extracorporeal membrane oxygenation, ECMO) auch bei erwachsenen Patienten zu einem festen Bestandteil der therapeutischen Optionen in der Behandlung des akuten Lungenversagens (ARDS, acute respiratory distress syndrome) geworden. Die beiden bislang durchgeführten randomisierten Vergleichsstudien konnten allerdings keinen Vorteil im Hinblick auf die Letalität verglichen mit konventioneller Beatmungstherapie belegen. In der Konsequenz resultierte aus beiden Studien keine Empfehlung für die ECMO-Therapie (1–3). Mittlerweile liegen weitreichende weltweite Erfahrungen (Gesamtzahl der therapierten erwachsenen Patienten Ende 2001 ca. 1000) vor. Wachsende Erfahrung und verbesserte Technik haben die Rate technischer Komplikationen der extrakorporalen Lungenersatztherapie deutlich reduziert. Aus einer Reihe von Gründen ist in der jüngsten Zeit die Inzidenz des Einsatzes von ECMO dennoch deutlich rückläufig. Einzelne Ein- und Ausschlusskriterien variieren zwischen den verschiedenen ECMO-Zentren. Potentielle Reversibilität der aktuellen Lungenschädigung und bei ausgeschöpfter konventioneller Therapie Fortbestand einer lebensbedrohlichen Gasaustauschstörung stellen jedoch übereinstimmende Grundvoraussetzung für die Durchführung einer ECMO-Therapie dar. Gebräuchliche Kriterien sind ein Murray lung injury score >3,5 (Röntgen-Befund, PaO2/FiO2 Ratio, statische Compliance=Cstat, PEEP) eine Morel-Klassifikation >3 (Röntgen-Befund, AaDO2/FiO2-Index, Cstat, PEEP), eine AaDO2 >600mmHg, ein intrapulmonaler Shunt QS/QT >30% und eine Erhöhung des extravaskulären Lungenwassers auf >15ml/kg KG. In manchen Zentren stellt darüber hinaus die Dauer der maschinellen Beatmung (2 Erythrozytenkonzentrate pro h), Alter >60 Jahre und – besonders in den USA – die Dauer der vorausgehenden invasiven Beatmung. Nach unserer Erfahrung optimiert ein frühzeitiger Kontakt zu einem ECMO-Referenzzentrum die Identifikation von Patienten die von einer ECMO-Therapie profitieren, die Gesamttherapie, den Transport und das Outcome. Auf Grund der hohen apparativen und personellen Anforderungen bei gleichzeitig sinkender Inzidenz sollte ECMO im Erwachsenensektor auf eine kleine Zahl Referenzzentren mit großer Erfahrung begrenzt bleiben. Damit lässt sich gleichzeitig eine ausreichende Routine aufrechterhalten. In Zeiten sich wandelnder ökonomischer Rahmenbedingungen kommt einer kritischen Indikationsstellung und hochqualifizierten Durchführung der ECMO-Therapie eine besondere Bedeutung zu.

In 2007, the German national guidelines on "Treatment of acute perioperative and post-traumatic pain" were published. The aim of this study was to describe current structure and process data for acute pain management in German hospitals and to compare how the guidelines and other initiatives such as benchmarking or certification changed the healthcare landscape in the last decade.All directors of German departments of anesthesiology according to the DGAI ("Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin", German Society for Anesthesiology and Intensive Care) were mailed a standardized questionnaire on structures and processes of acute pain management in their hospitals.A total of 403 completed questionnaires (46 %) could be evaluated. Of hospitals, 81 % had an acute pain service (ASD), whereby only 45 % met defined quality criteria. Written standards for acute pain management were available in 97 % of the hospitals on surgical wards and 51 % on nonsurgical wards. In 96 %, perioperative pain was regularly recorded (generally pain at rest and/or movement, pain-related functional impairment in 16 % only). Beside these routine measurements, only 38 % of hospitals monitored pain for effectiveness after acute medications. Often interdisciplinary working groups and/or pain managers are established for hospital-wide control. As specific therapy, the patient-controlled analgesia and epidural analgesia are largely prevalent ( 90 % of all hospitals). In the last decade, intravenous and oral opioid administration of opioids (including slow release preparations) has become established in acute pain management.The survey was representative by evaluating 20 % of all German hospitals. The organizational requirements for appropriate pain management recommended by the German guidelines for acute pain recommended have been established in the hospital sector in recent years. However, the organizational enforcement for acute pain management in nonsurgical areas is not adequate yet, compared to the perioperative care. In all hospitals modern medication and invasive techniques are widely available.

Background and Objectives The immune response to the transfused autologous buffy coat content in whole blood has, to date, not been studied in detail. Subjects and Methods Patients undergoing hip arthroplasty were studied according to whether they received autologous whole blood (WB) (n = 30), autologous fresh-frozen plasma and buffy coat-poor red cells (RC) (n = 40), or no transfusion (NT) (n = 27). Plasma levels of tumour necrosis factor-α (TNF-α), interleukin-6 (IL-6) and complement SC5b-9 were analysed by enzyme-linked immunosorbent assay (ELISA) 7 days after surgery. Results There were no significant between-group differences regarding the time course of TNF-α, IL-6 and complement SC5b-9 plasma level changes, the infection rate, or the length of hospital stay. Conclusion In comparison to the impact of surgery on cytokine and complement levels, the transfusion of autologous buffy coat is not relevant.

In previous studies, conflicting intensive insulin therapy (IIT) results have been observed, whereby IIT-related mortality seems to be lower in specific clinical subgroups. The aim of this study was to assess differences in glycaemic control, the risk of critical hypoglycaemia (≤ 2.2 mmol/l), the associated predisposing factors, and the in-hospital mortality in different clinical subgroups treated with IIT.Prospective, observational study in a university-affiliated intensive care unit (ICU) conducted from 2004 to 2005. All patients (n = 1667) belonging to one of the six most common surgical intervention groups (cardiac, neuro, abdominal, vascular, orthopaedic, and spinal surgeries) and medical patients were included. IIT was performed with a target blood glucose level of 4.4-7.8 mmol/l. Different indices were analysed to evaluate glucose control and glycaemic variability.The rate of critical hypoglycaemia was significantly different within the different clinical subgroups and varied from 0.8% to 4.5%. Similar results were obtained for hyperglycaemia. Multivariable analyses for the predisposing factors of critical hypoglycaemia showed a heterogeneous distribution pattern among the different clinical subgroups. Similar results were obtained for the risk factors of in-hospital mortality.The risk of critical hypoglycaemia and the associated predisposing factors depended on the clinical subgroup involved. Critical hypoglycaemia is a potential threat for our patients, and the high risk of critical hypoglycaemia in some clinical subgroups appeared to reverse the benefits of IIT. As a result, it is crucial that the different subgroups involved in a study are defined to further interpret the potential benefits of IIT and the risk of critical hypoglycaemia.

To reduce allogeneic blood transfusion requirements during extracorporeal membrane oxygenation (ECMO) we evaluated an autotransfusion device which processes and retransfuses erythrocytes of changed ECMO-systems. We studied 10 elective changes of ECMO-systems in 7 patients. Hemoglobin levels, the amount of retransfused autologous blood and of transfused allogeneic packed red blood cell units were documented within 48 h after the system change and compared to the measurements obtained from former ECMO-system changes without using any autotransfusion device. We determined the Horrowitz-index, Interleukin 6, 10, TNF-α and endothelin-I concentrations and coagulation parameters during the 48 hours after system change to study the compatibility of this procedure. Allogeneic blood transfusion was reduced from 7 to 2 units of packed red cells using the autotransfusion device. Additionally, no hints of any harmful side effects in these patients was observed.

To investigate the role of the monocyte/macrophage system in acute pancreatitisProspective clinical studyUniversity clinic, Germany37 consecutive patients who presented with acute pancreatitis.Correlation between function of monocytes measured by HLA-DR expression and outcomePatients were divided into three groups according to outcome: those with severe pancreatitis who died (n = 10), those with severe pancreatitis who survived (n = 15), and those with mild pancreatitis who survived (n = 12). There was a clear and significant difference between those with severe and those with mild disease. HLA-DR expression was initially depressed in both groups, but after the third day of treatment it started to recover significantly in those with mild disease (p0.05). The difference was also significant from day 7 onwards between those with severe disease who died and those with severe disease who survived (p0.05).Monocyte function as measured by HLA-DR expression (CD14+DR+) is reduced in patients with acute pancreatitis and does not recover in patients who are going to die (median20 relative antigen density units; RU).

Perfluorcarbone (PFC) sind kunstliche Sauerstofftrager, die ursprunglich als Blutersatzstoffe entwickelt wurden. Auf Grund ihrer spezifischen Eigenschaften ist daruber hinaus ihr Einsatz bei ischamischen Perfusionsstorungen von potentiellen Nutzen. Neuere Perfluorcarbonpraparationen verfugen uber eine hohere Sauerstofftransportkapazitat und sind mit weniger Nebenwirkungen behaftet als die PFC der ersten Generation. Altere und neuere PFC-Emulsionen, die fur die intravaskulare Applikation geeignet sind, wurden und werden im Tierversuch fur den Einsatz in ischamischen Gebieten des Herzens und des Gehirns untersucht. In dieser Arbeit werden praklinische Studien bei Infarkten und Reperfusionsschaden beschrieben und potentielle Nutzungsmoglichkeiten dieser Substanzgruppe fur diese Indikationsstellung diskutiert.

Organ transplantation is the only treatment option for many patients with end-organ failure. Due to lack of transplantable organs, patients already on the waiting list die every day. The number of organ donors in Germany fell in 2012 by 12.8 %, reaching its lowest level since 2002. The medical and nursing personnel in intensive care units have a key role in the recruitment of potential organ donors; therefore, a survey was conducted on this subject.At the 12th Congress of the German Interdisciplinary Association for Intensive and Emergency Medicine (DIVI) in December 2012, a point prevalence study using a paper-pencil survey was performed.A total of 1045 questionnaires were analyzed. Of respondents, 81 % favor organ donation in the event of their own brain death. The approval rate in the medical profession was 84 % and 75 % of the nursing profession. Only 45.3 % of the participants (47 % physicians, nursing 44 %) had an organ donor card and nearly half (45 %) had already confided their opinion towards organ donation to their family or friends. The main reasons for a lack of acceptance of organ donation was the concept of brain death (40 %), fear of abuse by organ trade (29 %), and the lack of integrity of the body after death (11 %). The particularly intense discussion about organ donation and transplantation in 2012 resulted in a predominantly negative change of attitude in 45 % of respondents.The vast majority of the intensive care personnel supports organ donation, but less than half of the respondents have an organ donor card. The reports of irregularities in the organ allocation were scrutinized, but had apparently no significant impact on the individual and collective fundamental donor decision.

Pre-existing or chronic pain is a relevant risk factor for severe postoperative pain. The prevalence of pre-existing and chronic pain in hospital depends on the time definition used and is approximately 44 % and 33%, at 3 or 6 months, respectively. The aim of this study was to determine the prevalence and importance of pre-existing pain in patients treated by a postoperative acute pain service (APS) and to evaluate the requirements for treatment and resources as well as its quality in this context.This study involved an evaluation of all visits by the APS of the University Hospital in Göttingen over an 8-week period including patient subjective quality assessment on the basis of the quality improvement in postoperative pain therapy (QUIPS) questionnaire. Pre-existing pain (12 weeks) was assessed by recording patients history of pain by members of the APS. The results from patients with and without pre-existing pain were compared.A total of 128 patients (38% female, 62% male, aged 15-88 years old, mean age 59.8 ± 14.4 years) were seen by the APS on 633 occasions. Of these patients 91% had been admitted to hospital for surgery (66% for tumor surgery, 8% joint replacement, 9% other joint surgery and 16% other interventions), 50% had acute postoperative pain without pre-existing pain, 50% had had pre-existing pain for at least 12 weeks, 31% had chronic non-cancer pain and 19% pain possibly related to cancer. Patients with pre-existing pain showed no significant differences in the treatment requirements (e.g. adjustment of medication), use of resources (e.g. number of visits to the APS and time spent in hospital) and quality of care (e.g. pain intensity, functional aspects, side effects and complications) in the setting of the APS. However, there was an additional subsequent support by chronic pain and palliative care services.Pre-existing pain is a common comorbidity in surgery patients treated by the APS. There were no significant differences in treatment requirements and quality of care between the patients. This is in contrast to other studies of postoperative pain management which showed that patients with pre-existing postoperative pain had higher pain intensity. This indicates indirectly that the presence of pre-existing pain should be further evaluated as a potentially useful indication for the support by an APS. However there is an urgent need for further studies to clarify whether this indirect effect can be replicated at other hospitals or in other patient collectives. Also it has to be clarified what benefits pain patients have from this kind of treatment: if they benefit from the APS in general or from the special technique, if there is a long-term effect lasting beyond treatment in the APS or if this group of patients would benefit in general from multiprofessional and non-invasive concepts of acute pain treatment.

Die akute Pankreatitis (AP) induziert abhangig von ihrer Verlaufsform odematos oder nekrotisierend systemische Komplikationen, deren Pathogenese ungeklart ist. Der Nachweis von Cytokinen im Blut dieser Patienten konnte einen Beitrag zur Pathophysiologie der systemischen Fruhkomplikationen der AP liefern. Weiterhin kann der Anstieg der Cytokine im Blut einen Hinweis auf den Schweregrad der Pankreatitis geben. Im Zeitraum von Oktober 1992 bis August 1993 wurden 23 Patienten mit einer AP im Rahmen einer prospektiven Beobachtungsstudie dokumentiert und Serum fur die Messung der Cytokine in einem gewerblichen ELISA und des C-reaktiven-Proteins (CRP) nephelometrisch gewonnen. Sechs der 11 Patienten mit nekrotisierender AP sind fruh (n = 1) oder an spaten septischen Komplikationen gestorben. Keiner der 12 Patienten mit odematoser AP verstarb. Es wurde jeweils das Maximum der Cytokin- bzw. CRP-Konzentration in den ersten drei Tagen zur Bewertung herangezogen. Die IL-6-Werte im Plasma reichten von 0 bis 2664 pg/ml. Im Verlauf der Erkrankung fielen die Werte unabhangig von weiteren Komplikationen gegen 0. Das Maximum der IL-6-Konzentration in den ersten 3 Tagen klassifizierte – bei einem Grenzwert von 600 pg/ml – bei 20 Patienten richtig die odematose oder nekrotisierende AP (Sensitivitat: 82 %, Spezifitat: 91 %, p < 0,001). Die Plasmawerte fur IL-8 reichten von < 100 bis 1381 pg/ml und zeigten zwar wahrend der ersten Tage die hochsten Werte, wiesen aber im Gegensatz zum IL-6 mehrere Anstiege im weiteren Verlauf auf. Das Maximum der IL-8-Konzentration korrelierte – bei einem Grenzwert von 200 pg/ml – nur bei 18 Patienten mit der Form der AP (Sensitivitat 82 %, Spezifitat 75 %, p < 0,01). Das CRP im Serum der Patienten lag zwischen 0 und 535 mg/l. Bei der nekrotisierenden AP fanden sich entsprechend den Cytokinen deutlich hohere Werte im Vergleich zur odematosen AP. Bei einem Grenzwert von 200 mg/l fur das CRP-Maximum in den ersten 3 Tagen wurden 18 von 22 Patienten richtig klassifiziert, entsprechend einer Sensitivitat und Spezifitat von 82 % (p < 0,01). Es fand sich keine Korrelation zwischen den Plasmawerten der Cytokine und der Letalitat. Das Cytokin TNF-α war im Verlauf der Proben von 5 Patienten mit odematoser oder nekrotisierender AP nicht nachweisbar. Die Konzentration vor allem des Cytokins IL-6 und weniger des Cytokins IL-8 sowie des CRP gibt Hinweise auf den Verlauf der AP in der Fruhphase. Da ihnen eine zentrale Rolle in der immunologischen Reaktion zukommt, kann eine zum Teil exzessive Stimulation der spezifischen Zellen (Makrophagen, Lymphocyten und Endothelien) im Verlauf der AP angenommen werden. Hieraus folgen die systemischen Fruhkomplikationen der AP.

Introduction Giant inguinoscrotal hernias are rare but still exist even in developed countries. Although accompanied by a higher perioperative mortality, an elective surgical approach should be undertaken. In critically ill patients, however, the surgical intervention requires specific demands. Methods We report a case of a 45-year-old man who was referred to the hospital after perforation of the hernia with concomitant peritonitis and sepsis. Results After initial stabilization of the patient, a subtotal colectomy and a partial small bowl resection was performed. In a second step after stabilization of organ functions, the hernia sac was resected, and the abdominal cavity was reconstructed. The patient was discharged and is doing well until today but still refuses any plastic surgery. Conclusion Resection of giant inguinoscrotal hernia is feasible even in patients being administered in an emergency setting. Especially in case of an intra-abdominal infection, intestinal resection is the therapy of choice to allow the reconstruction of the abdominal cavity. A two-step approach should be considered to allow a successful recovery.

Acute renal failure (ARF) ranks among the most frequent complications in critically ill patients and continuous renal replacement therapy (CRRT) is a typical treatment regimen in intensive care patients. Contributing factors to ARF, such as septic shock and hemodynamic instability require extended hemodynamic monitoring, and the simultaneous use of CRRT and cardiac output measurement is common. In view of this, a systematic analysis of the interaction between CRRT and cardiac output measurements by thermodilution is warranted. Cardiac output (CO) is commonly measured with thermodilution-based methods in critically ill patients. The methods are accurate but the measurements are affected by inconstant indicator volumes or changes in blood temperature. Because continuous renal replacement therapy (CRRT) may alter blood volume and temperature, we investigated its effect on thermodilution-based CO measurement.Thirty-two intensive care patients with both CRRT and CO monitoring were studied. Hemodynamic parameters were first measured in quintuple with bolus injections of cold saline during CRRT. Further five measurements were performed after CRRT had been shut off, and a final five measurements were performed after it had been restarted. Fifty measurement series were performed in patients with a pulmonary artery catheter and 25 in patients using a transpulmonary thermodilution method (PiCCO®).The first measurements in each series after switching CRRT off or on deviated most markedly from the average. When these measurements were excluded, the averaged CO values with and without CRRT differed significantly but by7% (P0.05).Substantial measurement error was only observed immediately after CRRT was switched off or on. Subsequent CO measurements did not depend on the CRRT status. Interrupting CRRT before measuring CO is not generally recommended, however, if interrupted, it is crucial to wait for blood temperature to reach a steady state before initiating the first measurements.

During neurally adjusted ventilatory assist (NAVA), the inspiratory support is controlled by the patients' respiratory drive influenced by an operator-controlled gain factor (NAVA level). The purpose of our observational study was to transfer patients from conventional pressure support ventilation (PSV) to NAVA safely. We compared two approaches to set the NAVA level and evaluated the effect of NAVA.We studied mechanically ventilated patients capable of spontaneous breathing. For the change of the ventilator mode, we used a NAVA level calculated to generate a peak inspiratory pressure equal to PSV. We compared this NAVA level with a NAVA level determined by a NAVA level titration. Ventilatory and haemodynamic data were recorded during an observational period of 6 h.All 20 patients included in the study could be transferred from PSV to NAVA and completed the observation interval. Setting the NAVA level according to prior PSV settings proved to be a feasible approach, but in 75% of our patients, we modified the NAVA level according to the titration results. Gas exchange and ventilatory mechanics during the observation interval remained stable.The ventilator mode NAVA seems to be well tolerated in a heterogeneous group of critically ill patients. Pre-setting of the NAVA level during PSV can result in an overestimation of the required ventilator support. An additional titration of the NAVA level ads valuable information although difficult to interpret in some cases.

Blind insertion of endotracheal tubes through the intubating laryngeal mask airway (ILMA) is unsuccessful in almost 50% of cases on the first attempt, with an overall success rate of approximately 90%. We used a portable fiber optic device (Foley Airway Stylet Tool® FAST) to detect the reasons for failed intubations and tested its use in facilitating endotracheal tube placement.Thirty patients without anticipated intubation difficulties participated in the study. The fiber optic device was fastened with its tip at the end of the endotracheal tube, and both instruments were advanced through the previously inserted ILMA past the lifting bar. The view was scored in the following manner: I, full view of laryngeal inlet; II, partial vocal cords, arytenoids, epiglottis; III, epiglottis; IV, no laryngeal structures identifiable. The ILMA was adjusted for the best obtainable view, which was scored, and the endotracheal tube was inserted.The initial laryngeal view was I in four patients, II in eighteen patients, III in one patient and IV in seven patients. The best view after corrective maneuvers was I in twenty-seven patients, II in two patients and IV in one patient. First attempt tracheal intubations were successful in twenty-seven (90%) patients; two patients required a second attempt.A grade II view or worse indicated misalignment of the ILMA with the glottis. An endotracheal tube inserted blindly through the misaligned ILMA will impinge on and potentially damage laryngeal structures. The use of a portable fiber optic device can help reduce the failure rate of endotracheal intubations by utilizing ILMA in emergent situations.

Acute lung failure is associated with high mortality and usually requires mechanical ventilation to ensure adequate gas exchange. However, mechanical ventilation itself can be associated with major complications and can aggravate pre-existing lung disease, thus contributing to morbidity and mortality. Extracorporeal gas exchange is increasingly used when conventional mechanical ventilation has failed. In contrast to veno-venous extracorporeal membrane oxygenation (ECMO), pumpless extracorporeal interventional lung assist (iLA) is applied via an arterio-venous bypass into which a gas exchange membrane is integrated. iLA allows for efficient carbon dioxide removal, which allows for a significant reduction in ventilator settings. iLA may be a useful tool in protective or even 'ultraprotective' ventilation, enabling the application of very low tidal volumes in patients with acute respiratory failure of different etiologies. This article reviews the current status and the potential role of interventional (pumpless) lung-assist iLA within the context of lung-protective ventilation strategies.

Modern processes in the organization in German hospitals are decisive to the development of emergency departments and as these represent the interface between outpatient and inpatient care, they have been identified as a strategic success factor. In larger hospitals emergency departments are generally run as independent units with their own management. The growing number of patients in emergency rooms each year demonstrates the future importance of these structures and successful hospital management has to face and handle this challenge. Clear job profiles for the leadership, staff members and structures of these units are needed. This article highlights the requirements for these structures from the perspective of the German Interdisciplinary Association of Critical Care Medicine (DIVI).

Pneumonia occurring more than 48 h after induction of mechanical ventilation is called ventilator-associated pneumonia (VAP). VAP is the most common nosocomial infection in intensive care medicine and is associated with prolonged intensive care and hospital stay and a higher mortality. The main pathomechanism for development of ventilator-associated pneumonia is not so much the mechanical ventilation per se but more the pathogens passing along the tube towards the lungs. Avoidance of tracheal intubation, strict hygienic measures, reduction of oropharyngeal colonization and the avoidance of microaspiration are the most promising prevention strategies. Therapeutic success in treatment of VAP is coupled to an early diagnosis and therapy. Suspicion of pneumonia is based on clinical and radiologic criteria. Biomarkers and microbiological findings are important for follow-up and reevaluation of the suspected diagnosis.

Despite the broad application of intraoperative warming new studies still show a high incidence of perioperative hypothermia. Therefore a prewarming program in the preoperative holding area was started.The efficacy of the prewarming program was assessed with an accompanying quality assurance check sheet over a period of 3 months.During the 3 month test period 127 patients were included. The median length from arrival in the holding area to beginning prewarming was 6 min and the average duration of prewarming was 46±38 min. During prewarming the core temperature rose by 0.3±0.4°C to 37.1±0.5°C and decreased to 36.3±0.5°C after induction of anesthesia. At the end of the operation the core temperature was 36.4±0.5°C and 14% of the patients were hypothermic.These data allow 2 conclusions: 1. Prewarming in the holding area is possible with a sufficient duration. 2. Prewarming is highly efficient even when performed over a relatively short duration.

Successful smoking cessation is associated with a survival benefit for patients with lung cancer. However, smokers newly diagnosed with non-small cell lung cancer and scheduled for curative resection are frequently discouraged from stopping smoking in the immediate preoperative period. This recommendation is based on the results of one single prospective cohort study published in 1998 which reported an increased risk of perioperative pulmonary complications in patients undergoing non-thoracic surgery who had reduced their tobacco consumption within the two months leading up to the operation. During the past 12 years, numerous observational studies have investigated the impact of preoperative smoking cessation on perioperative risk for thoracic and non-thoracic surgery. However, no more than six studies included patients with pulmonary neoplasms. Owing to methodological limitations and considerable heterogeneity of the included patient groups, the existing data are insufficient to support or refuse any recommendation regarding cessation advice for patients during the immediate preoperative phase. In view of the post-cessation recovery time-course of pathophysiological alterations relevant to the occurrence of perioperative complications, a smoke-free preoperative interval of 2 - 6 weeks appears most favourable. However, this is difficult to achieve as a curative resection should not be postponed. Since there is no scientific evidence demonstrating a negative impact of preoperative smoking cessation on prognosis, patients newly diagnosed with lung cancer should be encouraged to make an attempt to quit while waiting for thoracic surgery.

Extraglottic airway devices (EGA) are not only used in routine anaesthesia practice, they also have a distinct value for in-hospital and out-of-hospital difficult airway management. In the environment of the intensive care unit (ICU) EGA are not used on a regular basis. However, expertise and knowledge regarding EGA coming from the operating theatre or the out-of-hospital setting may also be of value for the ICU setting. This review presents the potential indications for EGA on the ICU for the management of difficult airway situations as well as during percutaneous tracheotomy. Furthermore, the possible advantages of EGA during postoperative recovery from anaesthesia as well as termination of controlled ventilation for intensive care patients are discussed.

Worldwide, sepsis is one of the leading causes of morbidity and mortality. In Germany about 79,000 (116/100,000) suffer from sepsis, and the incidence of severe sepsis and septic shock is about 75,000 cases per year. Patients are at high risk for irreversible organ failure and a lethal course. About 60,000 die from sepsis annually, and survivors have a reduced quality of life. It is presumed that demographic changes will lead to an increased incidence and overall mortality in the future. Additionally sepsis imposes a considerable economic burden to the society. Early and comprehensive treatment significantly improves outcome. An increased knowledge and awareness about the epidemiology, definitions and therapy of sepsis might contribute to the improved outcome. This review aims to present information on current definitions, epidemiology and the economic burden of sepsis.

Currently, tracheostomy represents an established procedure for airway management in critically ill patients who require long-term respiratory support, and it is one of the most frequently performed surgical procedures in critically ill patients. It offers a number of practical and theoretical advantages when compared to conventional translaryngeal oro- or nasotracheal intubation, but is also associated with a number of serious complications. In the last 20 years, several retrospective studies, randomized prospective trials, and meta-analyses have been published to determine the best timing for tracheostomy. However, these studies presented conflicting results. All studies performed so far in a prospective randomized fashion were relatively small and underpowered. Currently, several large controlled randomized studies are underway that will hopefully help physicians make better evidence-based decisions on the timing of tracheostomy. Based on our current knowledge, the following recommendations might be made on a low level of evidence: on day 2 or 3 after onset of mechanical ventilation (48 h of mechanical ventilation or need for an artificial airway) tracheostomy should be seriously considered. Before decisions are made, several questions should be answered: Is the situation suitable for tracheostomy? Are there relevant contraindications for the performance of a tracheostomy? What is the most likely course of the underlying respiratory insufficiency? What is the likelihood the patient will stay in need of invasive mechanical ventilation for more than a week, either because of an ongoing impairment of oxygenation, weaning failure, upper airway obstruction, coma or a swallowing disorder? If no relevant contraindication is present and if the need for invasive mechanical ventilation can be expected to last for more than one week, tracheostomy should be planned and performed within the next 2 days.

The aim of mechanical ventilation is to assure gas exchange while efficiently unloading the respiratory muscles and mechanical ventilation is an integral part of the care of patients with acute respiratory failure. Modern lung protective strategies of mechanical ventilation include low-tidal-volume ventilation and the continuation of spontaneous breathing which has been shown to be beneficial in reducing atelectasis and improving oxygenation. Poor patient-ventilator interaction is a major issue during conventional assisted ventilation. Neurally adjusted ventilator assist (NAVA) is a new mode of mechanical ventilation that uses the electrical activity of the diaphragm (EAdi) to control the ventilator. First experimental studies showed an improved patient-ventilator synchrony and an efficient unloading of the respiratory muscles. Future clinical studies will have to show that NAVA is of clinical advantage when compared to conventional modes of assisted mechanical ventilation. This review characterizes NAVA according to current publications on this topic.

A paediatric emergency case with a rescue helicopter, which was reported as unexpected cardiac arrest of a 4-year-old child will be described. Based on this case, the symptoms and therapy of meningococcal sepsis and Waterhouse-Friderichsen-Syndrome under emergency conditions will be discussed as well as aspects of post-exposure prophylaxis.