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Background Patients suffering from COVID-19 with pre-existing chronic heart failure (CHF) are considered to have a significant risk regarding morbidity and mortality. Similarly, older patients on the intensive care unit (ICU) constitute another vulnerable subgroup. This study investigated the association between pre-existing CHF and clinical practice in critically ill older ICU patients with COVID-19. Methods Patients with severe COVID-19 and who were ≥70 years old were recruited from this prospective multicenter international study. Patients' treatment, follow-up, and pre-existing heart failure data were collected during ICU stay. Univariate and multivariate logistic regression analyses examined the association between pre-existing heart failure and the primary endpoint of 30-day mortality. Results The study included 3,917 patients, with 407 patients (17%) evidencing pre-existing CHF. These patients were older (77±5 versus 76±5, p Conclusion In critically ill old COVID-19 patients, pre-existing chronic heart failure is associated with significantly increased short- and long-term mortality, but heart failure is not independently associated with increased 30-day mortality when adjusted for confounders. Funding Acknowledgement Type of funding sources: Public hospital(s). Main funding source(s): This study was endorsed by the ESICM. Free support for running the electronic database and was granted from the dep. of Epidemiology, University of Aarhus, Denmark. The support of the study in France by a grant from “Fondation Assistance Publique-Hôpitaux de Paris pour la recherche” is greatly appreciated. In Norway, the study was supported by a grant from the Health Region West. In addition, the study was supported by a grant from the European Open Science Cloud (EOSC). EOSCsecretariat.eu has received funding from the European Union's Horizon Programme call H2020-INFRAEOSC-05-2018-2019, grant agreement number 831644. This work was supported by the Forschungskommission of the Medical Faculty of the Heinrich-Heine-University Düsseldorf, No. 2018-32 to GW and No. 2020-21 to RRB for a Clinician Scientist Track.

In Europe, intravenous fosfomycin (IV) is used particularly in difficult-to-treat or complex infections, caused by both Gram-positive and Gram-negative pathogens including multidrug-resistant strains. Here, we investigated the efficacy and safety of intravenous fosfomycin under real-life conditions.Prospective, multi-center, and non-interventional study in patients with bacterial infections from 20 intensive care units (ICU) in Germany and Austria (NCT01173575).Overall, 209 patients were included (77 females, 132 males, mean age: 59 ± 16 years), 194 of which were treated in intensive care (APACHE II score at the beginning of fosfomycin therapy: 23 ± 8). Main indications (± bacteremia or sepsis) were infections of the CNS (21.5%), community- (CAP) and hospital-acquired pneumonia (HAP)/ventilator-associated pneumonia (VAP, 15.3%), bone and joint infections (BJI, 11%), abdominal infections (11%), and bacteremia (10.5%). Most frequently identified pathogens were S. aureus (22.3%), S. epidermidis (14.2%), Enterococcus spp. (10.8%), E. coli (12.3%) and Klebsiella spp. (7.7%). At least one multidrug-resistant (MDR) pathogen was isolated from 51 patients (24.4%). Fosfomycin was administered with an average daily dose of 13.7 ± 3.5 g over 12.4 ± 8.6 days, almost exclusively (99%) in combination with other antibiotics. The overall clinical success was favorable in 81.3% (148/182) of cases, and in 84.8% (39/46) of patients with ≥ 1 MDR pathogen. Noteworthy, 16.3% (34/209) of patients developed at least one, in the majority of cases non-serious, adverse drug reaction during fosfomycin therapy.Our data suggest that IV fosfomycin is an effective and safe combination partner for the treatment of a broad spectrum of severe bacterial infections in critically ill patients.

Regional citrate anticoagulation (RCA) in continuous renal replacement therapy can effectively anticoagulate dialysis circuits without having adverse effects on systemic heparin application. In particular, in continuous renal replacement therapy RCA is well established and represents a safe procedure with longer filter lifetimes and fewer bleeding complications.To provide guidance on the indications, advantages and disadvantages, and use of RCA, current recommendations from the renal section of the DGIIN (Deutschen Gesellschaft für Internistische Intensivmedizin und Notfallmedizin), ÖGIAIN (Österreichischen Gesellschaft für Internistische und Allgemeine Intensivmedizin und Notfallmedizin) and DIVI (Deutschen Interdisziplinären Vereinigung für Intensiv- und Notfallmedizin) are stated.The recommendations in this paper are based on the current KDIGO (Kidney Disease: Improving Global Outcomes) guidelines, other published guidelines and protocols as well as the expert knowledge and clinical experience of the authors.The use of commercially available machines with coupled pumps and integrated safety features, effective personal training and standardized protocols for clinical usage (SOP) is particularly important for the safe clinical use of RCA in renal replacement therapy. Contrary to previous recommendations, even liver failure or shock with lactic acidosis may no longer be an absolute contra-indication for RCA. However, these particular patients have to be carefully monitored for signs of citrate accumulation.

Intensive care patients with renal failure or insufficiency comprise a heterogeneous group of subjects with widely differing metabolic patterns and nutritional requirements. They include subjects with various stages of acute kidney injury (AKI), acute-on-chronic renal failure (A-CKD), without/with renal replacement therapy (RRT), chronic kidney disease (CKD), and subjects on regular hemodialysis or peritoneal dialysis therapy (HD/PD).Development of recommendations by the renal section of DGIIN (Deutsche Gesellschaft für Internistische Intensivmedizin und Notfallmedizin), ÖGIAIN (Österreichische Gesellschaft für Internistische und Allgemeine Intensivmedizin und Notfallmedizin) and DIVI (Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin) for the metabolic management and the planning, indication, implementation, and monitoring of nutrition therapy in this heterogeneous group of patients.The recommendations are based on recent evidence and current recommendations of DGEM (Deutsche Gesellschaft für Ernährungsmedizin), ASPEN (American Society for Parenteral and Enteral Nutrition) and ESPEN (European Society for Clinical Nutrition and Metabolism) and also the KDGIO (Kidney Disease: Improving Global Outcomes) clinical practice guidelines for AKI and the expert knowledge and clinical experience of the authors.Nutrition support in these patient groups is not fundamentally different from that in other disease states but must consider the multiple variations in metabolism and nutrient requirements. Nutrition therapy must be adapted to the stage of disease and especially, in those patients on RRT. Nutritional needs can differ widely between patients but also in the same patient during the course of the disease.Thus, the patient with renal failure requires an individualized approach in nutrition support and because of the altered metabolism of many nutrients and intolerances for electrolytes and fluids, the nutrition support in patients with renal insufficiency requires close clinical and laboratory monitoring.

Acute kidney injury (AKI) is a common complication in intensive care unit (ICU) patients. The incidence of AKI in ICU patients exceeds 50% and the associated morbidity and mortality rates increase with severity of AKI. In addition, long-term consequences of AKI are underestimated and several studies show impaired long-term outcome after AKI. In about 5-25% of ICU patients with AKI renal replacement therapy (RRT) is required.To assist in indication, timing, modality and application of renal replacement therapy of adult patients, current recommendations from the renal sections of the DGIIN (Deutschen Gesellschaft für Internistische Intensivmedizin und Notfallmedizin), ÖGIAIN (Österreichischen Gesellschaft für Internistische und Allgemeine Intensivmedizin und Notfallmedizin) and DIVI (Deutschen Interdisziplinären Vereinigung für Intensiv- und Notfallmedizin) are stated.The recommendations stated in this paper are based on the current KDIGO (Kidney Disease: Improving Global Outcomes) guidelines, recommendations from the 17th Acute Disease Quality Initiative (ADQI) Consensus Group, the French Intensive Care Society (SRLF) with the French Society of Anesthesia Intensive Care (SFAR) and the expert knowledge and clinical experience of the authors.Today, different treatment modalities for RRT are available. Although continuous RRT and intermittent dialysis therapy as well as continuous dialysis therapy have comparable outcomes, differences exist with respect to practical application as well as health-economic aspects. Individualized risk stratification might be helpful to choose the right time to start and the right treatment modality for patients.

Many anti-infective drugs require dose adjustments in critically ill patients with acute kidney injury (AKI) and renal replacement therapy, in order to achieve adequate therapeutic drug concentrations.The fundamental pharmacokinetic and pharmacodynamic principles of drug dose adjustment are presented. Recommendations on anti-infective drug dosage in intensive care are provided.We established dose recommendations of selected anti-infective drugs based on information in the summary of product characteristics, published studies and recommendations, pharmacokinetic and pharmacodynamic considerations, and the experience and expert opinion of the authors.Out of a total of 37 anti-infective drugs (31 antibiotics, 2 antivirals, 4 antifungals) 8 can be administered independent of renal function. For 29 anti-infective drugs, a specific recommendation on drug dosage could be made in case of intermittent hemodialysis and for 24 anti-infective drugs in case of continuous hemo(dia)filtration.Recommendations on dosing of important anti-infective drugs in critically ill patients with AKI and renal replacement therapy are provided.

Acute kidney injury (AKI) occurs in 30-50% of all intensive care patients. Renal replacement therapy (RRT) has to be initiated in 10-15%. The early in-hospital mortality is about 50%. Up to 20% of all survivors develop chronic kidney disease after intensive care discharge and progress to end-stage kidney disease within the next 10 years. For timely initiation of prophylactic or therapeutic interventions, it is crucial to exactly determine the actual kidney function, i. e., glomerular filtration rate (GFR), and to gain insight into the further development of kidney function. Traditionally, renal function has been estimated using serum levels of creatinine or urea. Unfortunately, both are notoriously unreliable and insensitive in intensive care patients. Cystatin C has fewer non-GFR determinants when compared to creatinine and is more sensitive and accurate to detect early decreases of GFR. At present, new functional tests are discussed, namely the furosemide stress test (FST) and renal functional reserve (RFR). The FST consists of an intravenous infusion of 1.0-1.5 mg/kgBW furosemide to critically ill patients with AKI. An increase in urine output to100 ml/h is indicative of a GFR20 ml/min and almost certainly excludes progression to AKI stage III and need for RRT. Estimation of RFR can be made by short-term oral or intravenous administration of a high protein load. A subsequent increase in GFR defines the presence and the magnitude of functional reserve which can be activated. Loss of RFR is an indicator of loss of functioning nephron mass and incomplete recovery following AKI. Both FST and RFR can help to improve diagnosis and care of high-risk patients with acute and chronic kidney disease.

One of the prime aims of intensive care is to cure patients or at least to extend life duration, sometimes to the extent of losing quality of life. Palliative care aims to improve the quality of life of patients with life-limiting conditions; however, some patients need both intensive and palliative care. About 5-10% of all deaths in Germany and 20% of all deaths in the USA occur in an intensive care unit (ICU) and many of those as well as other patients may benefit from palliative care consultation. Palliative care consultations are increasingly available for intensive care patients but are still infrequently used.We aimed to determine the current situation of palliative patients in ICU settings: what is the impact of palliative care interventions on the quality of care of ICU patients? To what extent is palliative care support at ICUs available and to what extent is it used? Which factors trigger palliative care consultations?We set out with a search of PubMed, Scopus and other databases in English and on a) the impact of palliative care interventions on the quality of care of ICU patients, b) the utilization of palliative care support in ICUs and c) the factors which trigger palliative care consultations. We included both quantitative and qualitative studies to reflect the views of all parties involved. To emphasize the situation in German-speaking countries we also searched Google Scholar with search terms in German and added those results to the review. Additionally, hand-searched studies in English and in German were included.We screened 695 abstracts and identified 18 relevant articles of which 15 were from the USA and Great Britain, 1 each was from Austria, Germany and Switzerland. Palliative care is a meaningful addition to ICU standard treatment: it can improve quality of care and helps reduce length of stay in an ICU. It is unclear if the reduced length of stay leads to economic benefits; however, the utilization of palliative care is inconsistent and infrequent as is its acceptance among ICU physicians. Trigger factors can be used to improve the integration of palliative care support in ICUs and point out patients' unmet palliative needs.Trigger factors can reduce barriers which hold back the integration of palliative care in ICUs. Early integration of palliative care can improve quality of care by offering psychological support to patients and their families and by providing collegial consultation. An ongoing prospective study is investigating the acceptance of trigger factors in the daily routine among ICU physicians in Germany.

Nur wenige Komplikationen in der Herzchirurgie haben einen vergleichbar negativen Einfluss auf die Prognose des Patienten wie perioperative Nierenfunktionsstorungen, die heute unter der Abkurzung CSA-AKI („cardiac surgery-associated acute kidney injury“) zusammengefasst werden: bereits geringfugige Veranderungen des postoperativen Plasmakreatinins sind mit einer relevanten Prognoseverschlechterung assoziiert. Die vorliegende Arbeit stellt eine aktualisierte und erweiterte Zusammenfassung kurzlich publizierter Konsensus-Statements der Acute Dialysis Quality Initiative (ADQI) zum Themenkomplex CSA-AKI dar und gibt einen Uberblick uber die Epidemiologie dieser Komplikation, die nach gegenwartigem Verstandnis beteiligten pathophysiologischen Mechanismen, prophylaktische Masnahmen und therapeutische Ansatze. Wahrend zum gegenwartigen Zeitpunkt kein pharmakologischer Ansatz bekannt ist, der sich in grosen prospektiven Studien als effizient erwiesen hatte, eine postoperative Nierenfunktionsstorung zu vermeiden, zeigt die Zusammenstellung der pathophysiologischen Mechanismen deutlich, dass zahlreiche derjenigen Faktoren, die zu einer perioperativen Nierenfunktionsstorung beitragen, unter Einbindung aller beteiligten Fachdisziplinen durchaus klinisch modifizierbar und im Sinne guter klinischer Praxis mit den Zielen: Vermeidung endogener und exogener Noxen, Normoglykamie, Aufrechterhaltung einer adaquaten systemischen Perfusion, Euvolamie und eines, dem individuellen Verbrauch angemessenen Sauerstoffangebots sowie Vermeidung embolischer Komplikationen positiv beeinflusst werden konnen. Im Umkehrschluss kann CSA-AKI – zumindest partiell – auch als Ausdruck eines suboptimalen klinischen Managements betrachtet werden, welches klinikindividuell und interdisziplinar in Angriff genommen werden sollte. Die Therapiekonzepte, die zur Behandlung des etablierten CSA-AKI zum Einsatz kommen, unterscheiden sich nicht grundlegend von den Vorgehensweisen, die bei Patienten mit Nierenfunktionsstorungen anderer Atiologie angewendet werden. Allerdings scheint bei herzchirurgischen Patienten die fruhzeitige Initiierung einer Nierenersatztherapie – bevor uramische Komplikationen auftreten – mit einer gunstigeren Prognose verknupft zu sein. Die Gabe von Schleifendiuretika hat keinen positiven Einfluss auf den Verlauf des CSA-AKI. Auch die Gabe von Dopamin in „Nierendosis“ ist nicht geeignet, eine Nierenfunktionsstorung zu verhindern oder sinnvoll zu behandeln.

Increasing numbers of elderly patients with severe co-existing medical diseases undergo major surgery. With these patients there is also an accompanying risk of age-related cardiovascular complications such as life-threatening myocardial ischaemia. We present a patient who suffered a myocardial infarction after a hemicolectomy and suffered a cardiac arrest in the recovery room. The therapeutic options available (e.g. coronary artery bypass grafting, acute percutaneous coronary angioplasty and peri-operative thrombolysis) are discussed and the successful management of the case by coronary angioplasty and stent implantation is described.

Nach aktuellen epidemiologischen Daten treten Nierenfunktionsstorungen bei 1/3 aller intensivmedizinisch behandelten Patienten auf. Eine Nierenersatztherapie wird bei etwa 6–10 % erforderlich. Eine Abnahme der renalen Clearance erhoht die Morbidit€at und Letalit€at auch dann, wenn eine Nierenersatztherapie letztlich doch nicht erforderlich wird (Uchino et al. 2010). Seit einigen Jahren wird daher anstelle des Begriffs akutes Nierenversagen (ANV) die Bezeichnung akute Nierenfunktionsstorung („acute kidney injury“, AKI) verwendet. Der Schweregrad von Nierenfunktionsstorungen wird anhand der RIFLEoder AKIN-Kriterien festgelegt (Einzelheiten s. Kap. ▶ Intensivtherapie bei akutem Nierenversagen (ANV), extrakorporale Eliminationsverfahren und Plasmaseparation). Sp€atestens im Stadium 3 nach beiden Klassifikationen wird in der Regel eine Nierenersatztherapie erforderlich (Singbartl und Kellum 2012).

During partial liquid ventilation perfluorocarbons are eliminated mainly by evaporation via the airways. The effects of intrapulmonary perfluorocarbon volume, respiratory rate, tidal volume, as well as the level of end-expiratory pressure on perfluorocarbon elimination from isolated lungs, were studied. Nonperfused rabbit lungs underwent partial liquid ventilation (2-15 mL x kg(-1) perfluorocarbon) with variable levels of end-expiratory pressure (0-10 cmH2O), respiratory rates (15-60 breaths x min(-1)) and tidal volumes (3.3-10.0 mL x kg(-1)). Evaporative loss of perfluorocarbon was determined gravimetrically as rate of change in lung weight. At constant respiratory settings, intrapulmonary liquid volume determined evaporative loss in a nonlinear fashion. Mean evaporation at a liquid volume of 5 mL x kg(-1) was 13% lower compared to evaporation at a liquid volume of 15 mL x kg(-1). Any increase in end-expiratory pressure reduced perfluorocarbon evaporation, e.g. by approximately 50% when end-expiratory pressure was increased from 0 to 10 cmH2O. At constant end-expiratory pressure and perfluorocarbon filling evaporation increased in a linear fashion with increasing respiratory rate and tidal volume. In summary, the experiments suggested that evaporative loss of perfluorocarbons during partial liquid ventilation of isolated lungs is increased with increasing intrapulmonary liquid volume, respiratory rate and tidal volume and is reduced in a level-dependent fashion by the application of positive end-expiratory pressure.

The incidence of acute kidney injury (AKI) in critically ill patients is very high and is associated with an increased morbidity and mortality. In 2012 the Kidney Disease: Improving Global Outcome (KDIGO) guidelines were published in which evidence-based practical recommendations are given for the evaluation and management of patients with AKI. The first section of the KDIGO guidelines deals with the unification of earlier consensus definitions and staging criteria for AKI. The subsequent sections of the guidelines cover the prevention and treatment of AKI as well as the management of renal replacement therapy (RRT) in patients with AKI. In each section the existing evidence is discussed and a specific treatment recommendation is given. The guidelines appreciates that there is insufficient evidence for many of the recommendations. As a specific pharmacological therapy is missing, an early diagnosis, aggressive hemodynamic optimization, tight volume control, and avoidance of nephrotoxic drugs are the only interventions to prevent AKI. If renal replacement therapy is required different modalities are available to provide an effective therapy with a low rate of adverse effects.

Perioperative acute kidney injury (AKI) is common and is associated with adverse clinical outcomes, excess mortality, and an increased risk for chronic renal failure. Recommendations to prevent perioperative AKI include the early identification of patients at risk, the avoidance of nephrotoxic drugs, and early goal-directed haemodynamic stabilization. The major causes for perioperative AKI are severe sepsis and septic shock, hypovolemia, bleeding and cardiac failure.The choice of modality, i.e. intermittent or continuous renal replacement (CRRT) therapy, can be made based on local resources. However, surgical patients frequently have impaired haemodynamics, a decreased pulmonary function and require removal of large amounts of fluid. In such cases, CRRT offers improved haemodynamic stability and volume control. Frequently, patients must be transferred to the operating theatre for redo procedures. Here, slow-extended daily dialysis treatments of 8-12 h can deliver a high dialysis dose with good haemodynamic stability at reduced costs. Surgical patients per se have an increased risk of bleeding. Regional citrate anticoagulation is a new and effective mode of anticoagulation which significantly reduces bleeding risk and transfusion requirements.Data from a recent meta-analysis show that, in surgical patients, mortality is reduced when renal replacement therapy is started early. In certain surgical diseases, i.e. acute occlusive disease of the abdominal aorta (Leriche's syndrome) following surgical reperfusion, patients are at risk of severe metabolic acidosis and life-threatening hyperkalemia. In such cases, intraoperative dialysis using a mobile batch system can help to avoid these complications by delivering an effective dialysis therapy at the time of reperfusion.

Non-invasive ventilation (NIV) is an evidence-based treatment of acute respiratory failure and can be helpful to reduce morbidity and mortality. In Germany national S3 guidelines for inhospital use of NIV based on a large number of clinical trials were published in 2008; however, only limited data for prehospital non-invasive ventilation (pNIV) and hence no recommendations for prehospital use exist so far.In order to create a database for pNIV in Germany a nationwide survey was conducted to explore the status quo for the years 2005-2008 and to survey expected future developments including disposability, acceptance and frequency of pNIV.A questionnaire on the use of pNIV was developed and distributed to 270 heads of medical emergency services in Germany.Of the 270 questionnaires distributed 142 could be evaluated (52 %). The pNIV was rated as a reasonable treatment option in 91 % of the respondents but was available in only 54 out of the 142 responding emergency medical services (38 %). Continuous positive airway pressure (98 %) and biphasic positive airway pressure (22 %) were the predominantly used ventilation modes. Indications for pNIV use were acute cardiogenic pulmonary edema (96 %), acute exacerbation of chronic obstructive pulmonary disease (89 %), asthma (32 %) and pneumonia (28 %). Adverse events were reported for panic (20 ± 17%) and non-threatening heart rhythm disorders (8 ± 5%), the rate of secondary intubation was low (reduction from 20 % to 10 %) and comparable to data from inhospital treatment.Prehospital NIV in Germany was used by only one third of all respondents by the end of 2008. Based on the clinical data a growing application for pNIV is expected. Controlled prehospital studies are needed to enunciate evidence-based recommendations for pNIV.

In humans, both nitric oxide (NO) and bradykinin, a naturally occurring algetic and a potent NO liberator, evoke pain from hand veins. The afferent innervation of these veins consists solely of polymodal nociceptors which are located close to the endothelium, a well-known source of NO, thus suggesting NO as a chemical link in nociception. Consistent with this hypothesis, our observations show that neither bradykinin, nor hyperosmolar solutions (a noxious physicochemical stimulus) evoke pain from hand vein segments that have been exposed to the NO-synthase (NOS) inhibitor N g -mono-methyl- l -arginine. An intact NOS pathway is therefore a prerequisite for pain to toe evoked by bradykinin and hyperosmolar solutions from veins, indicating for the first time in humans that vascular pain is mediated by NO. Thus, new directions for research on analgesics may be opened.

To study the pain-evoking properties of bradykinn on the nociceptive systems of skin, paravascular tissue and hand veins of humans, bradykinin was injected intracutaneously, retrogradially into occluded finger veins for reaching the paravascular tissue or into vascularly isolated hand vein segments of seven subjects. Regardless of the injection site, bradykinin always evoked pain of concentration-related intensity within nearly similar concentration ranges of 0.1-10.0 microM, yielding congruent pain intensity-concentration relations. Thus, in humans, the nociceptive systems of skin, deep tissue and hand veins are equally sensitive to the endogenous algetic bradykinin.

Current practices for renal replacement therapy (RRT) in ICU remain poorly defined. The observational DOse REsponse Multicentre International collaborative initiative (DO-RE-MI) survey addresses the issue of how the different modes of RRT are currently chosen and performed. The primary endpoint of DO-RE-MI will be the delivered dose versus in ICU, 28-day, and hospital mortality, and the secondary endpoint, the hemodynamic response to RRT. Here, we report the first preliminary descriptive analysis after 1-year recruitment.Data from 431 patients in need of RRT with or without acute renal failure (mean age 61.2+15.9) from 25 centers in 5 countries (Spain, Italy, Germany, Portugal, France) were entered in electronic case report forms (CRFs) available via the website acutevision.net.On admission, 51% patients came from surgery, 36% from the emergency department, and 16% from internal medicine. On admission, mean SOFA and SAPS II were 13 and 50, respectively. The first criteria to initiate RRT was the RIFLE in 38% (failure: 70%, injury: 25%, risk: 22%), the second the high urea/creatinine, and the third immunomodulation. A total of 3,010 cumulative CRF were reported: continuous venovenous hemodiafiltration (CVVHDF) 60%, continuous venovenous hemofiltration (CVVH) 15%, intermittent hemodialysis (IHD) 15%, high-volume hemofiltration (HVHF) 7%, continuous venovenous hemodialysis (CVVHD) 1%, and coupled plasma filtration adsorption/CVVD 2%. In 15% of cases, the patient was shifted to another modality. Mean blood flow rates (ml/min) in the different modalities were: 145 (CVVHDF), 200 (CVVH), 215 (IHD), 283 (HVHF), and 150 (CVVHD). Downtime ranged from 8 to 28% of the total treatment time. Clotting of the circuit accounted for 74% of treatment interruptions.Despite a large variability in the criteria of choice of RRT, CVVHDF remains the most used (49%). Clotting and clinical reasons were the most common causes for RRT downtime. In continuous RRT, a large variability in the delivered dose is observed in the majority of patients and often in the same patient from one day to another. Preliminary analysis suggests that in a large number of cases the delivered dose is far from the 'adequate' 35 ml/h/kg.

The aim of this study was to determine the incidence of renal dysfunction according to the Acute-Dialysis-Quality Initiative-(ADQI)-RIFLE grading system in cardiac surgery in Germany in 2003 and to determine if variations in the incidence of renal dysfunction are related to clinical practice patterns.prospective cohort analysis and practice pattern survey.81 hospitals were requested to report prospectively sampled quality-management-data on patient load, case mix, aortic-cross-clamp-time, baseline and maximal plasma creatinine (CreaP), new-onset-renal-replacement-therapy, and clinical practice concerning the use of fluids, inotropic and vasopressor drugs, and diuretics. Fifty-one (63%) centers answered the survey. Twenty-six centers (32%)(representative for 29 623 patients(reported creatinine data.The incidence of a 50%, 100%, or 150% increase in plasma creatinine (graded as risk, injury, and failure according to the ADQI-RIFLE-system) were 9% (2-40%), 5% (0.8-30%), and 2% (0.6-33%), respectively, overall 15.4% (3.1-75%). The incidence of new-onset renal-replacement-therapy was 4.5% (0.6-24%). Centers with a low incidence of renal dysfunction 8.7% (3.1-15.4%)differed from those with a high incidence 51% (15.7-75%)by being more liberal with fluids, not preferring dopamine in ''renal'' or inotropic doses, and preferring noradrenaline as a vasopressor (all: P0.05), but not by case mix, frequency of urgent or emergency cases, and the use of loop diuretics.Renal dysfunction is a frequent complication following cardiac surgery in many German heart centers. The variance between centers may not be explained by patient heterogeneity and may be related to different strategies regarding fluid therapy and the use of inotropes and vasopressors.

We report on a patient with a complicated course after surgical abdominal intervention and episodic life threatening respiratory failures successfully treated with carbamazepine after diagnosis of a ponto-medullary lesion in the MRI.

Conventional membranes used for CRRT have a limited middle molecule clearance. New membranes called super high-flux (SHF) or high cutoff membranes have been investigated. The loss of albumin with hemofiltration is a major drawback, but these membranes can be used in CVVHD with regional citrate anticoagulation (Ci-Ca® CVVHD), which may limit albumin loss, and contribute to a prolonged filter patency and an improved and stable middle molecule clearance. We evaluated saturation coefficients (SC), plasma clearances (PCL) and serum levels of eight small and middle molecules during 72 hours of Ci-Ca® CVVHD with a SHF membrane (Ultraflux®EMiC®2).

Nasal continuous positive airway pressure (nCPAP) is considered useful for prophylaxis and treatment of respiratory complications following major thoracic surgery. It is unknown, however, which CPAP levels are required to avoid alveolar derecruitment and to consistently improve pulmonary oxygen transfer in patients following thoracotomy. We therefore studied the effects of different nCPAP levels on pressure transmission into the trachea as well as on pulmonary oxygen transfer.In 10 consecutive patients after cardiac or thoracic vascular surgery, following extubation in the ICU, nCPAP was generated by means of a high-flow gas source and applied randomly at levels of 5 or 10 cm H2O. Airway pressure was recorded continuously in the nasal mask and the trachea. The PaO2/FiO2ratio was calculated from the tracheal oxygen concentration, and PaO2 was determined while breathing at an ambient and elevated airway pressure. Haemodynamic variables (heart rate, arterial blood pressure, central venous pressure) were also recorded.Mean pressures in the nasal mask were 5.4+/-0.1 and 9.7+/-0.3 cm H2O. Corresponding tracheal pressures were 2.8+/-1.0 vs. 7.2+/-1.1 cm H2O (P=0.007). With higher mask pressure, the fraction of pressure transferred from the nasal mask into the trachea was larger (0.75+/-0.03 vs. 0.52+/-0.05; P=0.04), and tracheal pressures remained positive during the entire respiratory cycle in all patients. In contrast, with 5.4 cm H20, negative pressure changes during inspiration occurred in five out of 10 patients. The PaO2/FiO2 ratio increased from 183+/-53 (ambient pressure) to 199+/-74 (nCPAP 5.4 cm H2O; P=0.25) and to 333+/-54 (nCPAP 9.7 cm H2O; P=0.003). Nasal CPAP did not alter hemodynamics.Nasal CPAP is an effective non-invasive means of increasing tracheal and thus intrathoracic pressure without adverse hemodynamic effects. Only mask pressures of 9-10 cm H2O were sufficient to consistently improve pulmonary oxygen transfer in patients following thoracotomy.

In a special inpatient unit for detoxification treatment of illicit drugs, antagonist-induced opiate detoxification was studied in five nonselected inpatients with polytoxicomanic abuse. The purpose was to evaluate the feasibility of this detoxification method and its impact on further reaction to treatment. During rapid detoxification under general anesthesia in an intensive care unit, no complications occurred. Withdrawal symptoms were observed in all patients over several days. During the inpatient period, no patient could be motivated to take part in a longer rehabilitation therapy. Most patients were discharged prematurely on their own demand and none made use of the rehabilitation program offered to them. All patients relapsed after relatively short times and three out of five presented for a new detoxification treatment.

To study whether nasal continuous positive airway pressure (nCPAP) improves pulmonary oxygen transfer and avoids reintubation in patients with severe nonhypercapnic oxygenation failure after major cardiac, vascular, or abdominal surgery.Prospective interventional study.Surgical ICU of a university hospital.Twenty consecutive patients after thoracic, abdominal, or combined thoracoabdominal operations, in whom pulmonary oxygen transfer deteriorated continuously following elective extubation after initial mechanical ventilation. Respiratory failure was due to atelectasis and/or left heart failure, and all patients met predefined criteria for reintubation.nCPAP therapy (8 to 10 cm H(2)O) was initiated if PaO(2) had decreased to80 mm Hg despite application of 100% oxygen (flow, 25 L/min), intermittent mask continuous positive airway pressure, and maximum conventional therapy.nCPAP treatment was started 24.1 +/- 3.4 h after elective extubation. PaO(2) was80 mm Hg in all patients, in 13 patients it was60 mm Hg, and in 3 patients it was50 mm Hg. Mean PaO(2)/fraction of inspired oxygen (FIO(2)) ratio had decreased to 60 +/- 2.6, and increased within the first hour of nCPAP to 136 +/- 12 (p0.001). The clinical condition in all patients improved further, and after 35.2 +/- 6.3 h, all patients were well oxygenated by face mask at ambient pressure (PaO(2)/FIO(2) ratio, 146 +/- 14). Two patients were reintubated for reasons unrelated to oxygenation or ventilation (data are presented as mean +/- SEM).nCPAP is safe, easy to apply, and effective to improve arterial blood oxygenation in1 h in postoperative patients with severe nonhypercapnic oxygenation failure. In these patients, who otherwise would have been reintubated, nCPAP can avoid endotracheal reintubation and mechanical ventilation.

A 73-year-old man without a history of coronary artery disease had two episodes of significant ST-segment elevation indicative of inferior myocardial ischemia during the resection of an abdominal aortic aneurysm. During the further course, sudden ST-segment elevations occurred and resolved spontaneously without preceding hemodynamic instability. The patient sustained two episodes of cardiac arrest due to ventricular fibrillation and intermittent third-degree atrioventricular block with ventricular asystole. On cardiac catheterization, coronary arteries had a right dominant pattern. The right coronary artery was entirely patent on multiple injections. Thus, right coronary artery spasm is the only possible explanation for these observations.

Blood vessels are similar to skin invested with substance P-containing nerves and the binding sites for substance P, which has been shown to be involved in nociception from skin. No attempts have been made so far to see whether substance P is also involved in vascular nociception. We therefore tested substance P for its algesic properties in human veins because their innervation exclusively subserves nociception. Substance P never evoked pain from veins at concentrations of 10(-8)-10(-4) M but did so in a concentration-related fashion from skin. Therefore, substance P is not involved in the generation of acute vascular pain.

The ability of low dose dopamine (1-3 micrograms x kg-1 x min-1) to cause selective renal vasodilation, to increase glomerular filtration rate, urine output, and natriuresis, is intuitively considered favourable. Dopamine, therefore, continues to be used in critically ill patients to preserve or improve renal function. Despite its application in a wide variety of disease states and in patients at risk of acute renal failure or with already decreased renal function, there is no conclusive evidence that "renal doses" of dopamine prevented acute renal failure or had any positive effect on patient outcome although it increased urine output and natriuresis consistently. Data from many clinical studies, however, are difficult to interpret due to small numbers of patients, the absence of control groups, the inability to exclude changes in cardiac output or to separate a diuretic effect of dopamine in the tubulus system from specific increases of glomerular filtration rate, and because of the variability of methods to determine renal performance (i.e. creatinine clearance, urine output, natriuresis, fractional excretion of sodium). Moreover, the routine use of dopamine is not innovous, since it may worsen gut ischaemia and suppress certain hormonal systems. Those who believe in the clinical benefits of "renal dose" dopamine argue that, even in the absence of an improvement in renal function, the maintenance of urine output could be useful in patients unresponsive to diuretics. Again, the clinical benefit of this diuretic action still needs to be shown. In conclusion, there is little justification for the routine administration of low-dose dopamine in patients at risk of renal failure. Large controlled clinical studies are urgently needed to determine whether dopamine improves renal function or prevents acute renal failure in patients at risk.

1. To see if pain from veins is mediated by C fibre endings, the C fibre stimulant capsaicin was applied intravenously, and, for comparison, paravenously and intracutaneously. 2. Capsaicin, dissolved in the fat emulsion Intralipid, was applied intravenously by continuous perfusion of vascularly isolated hand vein segments as well as by injections into occluded finger veins. Using the latter approach chemicals reach the paravascular space. 3. Pain intensities were recorded continuously with an electronically controlled visual analogue scale for deriving capsaicin concentration-pain intensity relations and the time course of pain (latencies, pain durations). 4. Capsaicin always evoked pain upon injection into skin and paravenous tissue (0.3-6.5 microM) and into occluded finger veins (3.3-33 microM), whereas it had no effect whatsoever when perfused through hand vein segments even at a concentration of 650 microM. 5. Pain intensity increased with concentration and usually reached the tolerance maximum at the fivefold threshold concentration, so that the concentration-pain intensity relations were congruent for the various routes of drug application. 6. The latencies and pain durations were independent of the capsaicin concentration, but were substantially longer with injections into occluded finger veins (latency 10-30 s, pain duration 60-120 s) than with intradermal or paravenous injections (2-9 s, 10-28 s). 7. These observations show for the first time a functional similarity between the nociceptive C fibre system of the skin and the paravascular tissues, and by inference, they dismiss the possibility that C fibre endings mediate pain in cutaneous veins.

Intensive insulin therapy reduces morbidity and mortality in postoperative critical care; however, this treatment also increases the risk of hypoglycemia. A possible cause for unstable blood glucose (BG) levels could be a variable adsorption of insulin at plastic material of infusion tubings. We evaluated in vitro and in vivo the adsorption of insulin at standard tubing materials (polyethylene (PE) and polyurethane (PU)) and the effects of this adsorption process on blood glucose levels.