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BACKGROUND AND AIMS: Patients with COVID-19 infection presents with a broad clinical spectrum of symptoms and complications. As a consequence nutritional requirements are not met, resulting in weight- and muscle loss, and malnutrition. The aim of the present study is to delineate nutritional complaints, the (course of the) nutritional status and risk of sarcopenia of COVID-19 patients, during hospitalisation and after discharge.METHODS: In this prospective observational study in 407 hospital admitted COVID-19 patients in four university and peripheral hospitals, data were collected during dietetic consultations. Presence of nutrition related complaints (decreased appetite, loss of smell, changed taste, loss of taste, chewing and swallowing problems, nausea, vomiting, feeling of being full, stool frequency and consistency, gastric retention, need for help with food intake due to weakness and shortness of breath and nutritional status (weight loss, BMI, risk of sarcopenia with SARC-F ≥4 points) before, during hospital stay and after discharge were, where possible, collected.RESULTS: Included patients were most men (69%), median age of 64.8 ± 12.4 years, 60% were admitted to ICU at any time point during hospitalisation with a median LOS of 15 days and an in-hospital mortality rate of 21%. The most commonly reported complaints were: decreased appetite (58%), feeling of being full (49%) and shortness of breath (43%). One in three patients experienced changed taste, loss of taste and/or loss of smell. Prior to hospital admission, 67% of the patients was overweight (BMI >25 kg/m2), 35% of the patients was characterised as malnourished, mainly caused by considerable weight loss. Serious acute weight loss (>5 kg) was showed in 22% of the patents during the hospital stay; most of these patients (85%) were admitted to the ICU at any point in time. A high risk of sarcopenia (SARC-F ≥ 4 points) was scored in 73% of the patients during hospital admission.CONCLUSION: In conclusion, one in five hospital admitted COVID-19 patients suffered from serious acute weight loss and 73% had a high risk of sarcopenia. Moreover, almost all patients had one or more nutritional complaints. Of these complaints, decreased appetite, feeling of being full, shortness of breath and changed taste and loss of taste were the most predominant nutrition related complaints. These symptoms have serious repercussions on nutritional status. Although nutritional complaints persisted a long time after discharge, only a small group of patients received dietetic treatment after hospital discharge in recovery phase. Clinicians should consider the risks of acute malnutrition and sarcopenia in COVID-19 patients and investigate multidisciplinary treatment including dietetics during hospital stay and after discharge.

ZusammenfassungMit der COVID-19-Pandemie stehen die Notaufnahmen als Schnittstelle der ambulanten und stationären Krankenversorgung vor einer großen Herausforderung. Die Dynamik der Pandemie zwang die Notfallversorgung des Universitätsklinikums Münster zu umfassenden Anpassungsprozessen, die in kürzester Zeit erfolgen mussten. Dazu gehörte die Etablierung einer ambulanten Coronateststelle und einer studentischen Telefonhotline. Innerklinisch wurden neue Isolationskapazitäten in der Notaufnahme sowie eine eigene COVID-19-Station eingerichtet. Der Patientenfluss wurde durch Flussdiagramme sowohl für den ambulanten als auch für den stationären Bereich neu geregelt. Das allgemeine und spezielle Notfallmanagement wurde für die reibungslose Versorgung COVID-19-positiver Patienten optimiert und das Personal in der Benutzung von Schutzausrüstung trainiert. Dieser Erlebnisbericht soll anderen Notaufnahmen in der Vorbereitung auf die COVID-19-Pandemie unterstützen.

With the COVID-19 pandemic, emergency rooms are faced with major challenges because they act as the interface between outpatient and inpatient care. The dynamics of the pandemic forced emergency care at the University Hospital Münster to extensively adjust their processes, which had to be carried out in the shortest time possible. This included the establishment of an outpatient coronavirus test center and a medical student-operated telephone hotline. Inside the hospital, new isolation capacities in the emergency room and a dedicated COVID-19 ward were set up. The patient flow was reorganized using flow diagrams for both the outpatient and inpatient areas. The general and special emergency management was optimized for the efficient treatment of COVID-19-positive patients and the staff were trained in the use of protective equipment. This report of our experience is intended to support other emergency departments in their preparation for the COVID-19 pandemic.

Das grampositive Bakterium Methicillin-resistenter Staphylococcus aureus (MRSA) ist ein bedeutender Erreger behandlungsassoziierter Infektionen (nosokomial). Die Inzidenz von Hospital-acquired (HA-)MRSA in der Bevolkerung und den Krankenhausern ist in Deutschland einer der am haufigsten nachgewiesenen multiresistenten Erreger. Da der Krankentransport eine der haufigsten Schnittstellen zwischen Wohnraum, ambulanter Behandlung und stationarer Behandlung von Patienten ist, ist der adaquate Umgang mit MRSA hier von herausragender Bedeutung. Mit welcher Wahrscheinlichkeit wird MRSA vom Patienten auf Kontaktflachen in Krankentransportfahrzeuge unter Beachtung eines Infektionsschutzkonzepts ubertragen und welche sind die hauptsachlichen Risikokontaktflachen im Fahrzeug? Wir untersuchten 360 definierte Indikatorkontaktflachen in 30 Krankentransportwagen nach Transport eines bekannt MRSA-positiven Patienten. In der Kontrollgruppe wurden 15 Krankentransportwagen ohne bekannten MRSA-Status des Patienten nach einem Transport untersucht. Bei 3 Transporten mit bekanntem MRSA-Status des Patienten fanden sich an 4 Kontaktflachen in den Fahrzeugen vor der Abschlussdesinfektion ein MRSA-Befund mit einem als nosokomial bekannten Genotyp des zuvor transportierten Patienten. In der Kontrollgruppe fand sich ein Zufallsbefund eines ebenso nosokomialen MRSA-Stammes auf dem Desinfektionsmittelspender. Die ermittelten Risikoflachen sind alle patientennahe und alle handnahen Bereiche des Personals. MRSA wird bei Krankentransporten nur in 10 % vom Patienten und lediglich auf patientennahe und alle handnahen Kontaktflachen im Krankentransportwagen ubertragen. Eine gezielte Desinfektion sowie ein Infektionsschutzkonzept konnen ausreichen, um eine MRSA-Ubertragung auf Kontaktflachen im Fahrzeug zu verhindern.

Storungen in der Kommunikation und Zusammenarbeit von leitenden Arzten und Geschaftsfuhrungen sind immer wieder zu beobachten. Uber diesen Storungen schwebt haufig eine noch in vielen Kopfen verankerte klassische Rollenteilung: Der leitende Arzt ist fur die fachliche und qualitatsorientierte Behandlung der Patienten zustandig; die Geschaftsfuhrung hat sich um die Bereitstellung der Mittel hierfur zu kummern. Leitende Arzte stehen jedoch gemeinsam mit der Geschaftsfuhrung in der Verantwortung, eine qualitativ hochwertige, aber auch wirtschaftlich effiziente Leistungserbringung sicherzustellen. Bekleiden sie als leitende Arzte in einem Universitatsklinikum gleichzeitig eine Universitatsprofessur, mussen sie zudem das Fach in Forschung und Lehre vertreten. Arzte, die eine tradierte Rollenteilung weiterleben, werden mit groser Wahrscheinlichkeit nicht erfolgreich ihre Interessen bei der Ausgestaltung und Weiterentwicklung ihrer Fachabteilung durchsetzen konnen. Daruber hinaus besteht die Gefahr, dass sie sich fortwahrend von der Geschaftsfuhrung unverstanden fuhlen und eine Rolle in permanenter Opposition zur Geschaftsfuhrung ausfullen.

Bei der Reanimation fuhrt die Unterbrechung der Thoraxkompression zu einer Verschlechterung der Uberlebenswahrscheinlichkeit des Patienten. Nach Veroffentlichung der ERC-Reanimationsleitlinien 2010 wurde im Rettungsdienst Munster ein lokales Protokoll zur nichtarztlichen Atemwegsicherung umgesetzt. Anstelle einer Masken-Beutel-Beatmung wurden Rettungsassistenten geschult, einen Larynxtubus als primaren Atemweg einzusetzen. In dieser retrospektiven Studie untersuchten die Autoren, inwieweit die Umsetzung des lokalen Protokolls die Unterbrechungen der Thoraxkompression verringert. Einschlusskriterium war, dass die Rettungswagenbesatzung mindestens 5 min vor dem Notarzt am Einsatzort eintraf. Eine Gruppe enthielt 27 Falle vor der Umsetzung des lokalen Protokolls, in denen primar die Masken-Beutel-Beatmung angewendet wurde. Die Vergleichsgruppe enthielt 27 Falle nach Schulung auf das neue Protokoll, d. h. die Beatmung mittels Larynxtubus durch Rettungsassistenten. Bei allen Einsatzen wurden 2 Beatmungen alternierend zu 30 Thoraxkompressionen durchgefuhrt. Analysiert wurde mit einem Echtzeit-Feedback-System. Der Anteil der Zeit ohne Thoraxkompression im Reanimationsverlauf konnte von 12,47 % auf 8,19 % gesenkt werden (p = 0,005), indem primar ein Larynxtubus zur Ventilation durch Rettungsassistenten verwendet wurde. Die Falle der beiden Kollektive unterschieden sich nicht hinsichtlich des initialen EKG-Rhythmus oder der Gesamtdauer der Reanimation. In dieser retrospektiven Analyse von 54 praklinischen Reanimationen, die mindestens 5 min durch Rettungsassistenten ohne Notarzt durchgefuhrt wurden, verkurzte der Einsatz eines Larynxtubus signifikant die Unterbrechungen der Thoraxkompression. Im Vergleich zur konventionellen Masken-Beutel-Beatmung scheint der Einsatz eines Larynxtubus durch Rettungsassistenten als primarer Atemweg Vorteile zu bieten.

GDF-15 prevents ventilator-induced lung injury by inhibiting the formation of platelet-neutrophil aggregates

Background Terlipressin bolus infusion may reduce cardiac output and global oxygen supply. The present study was designed to determine whether dobutamine may counterbalance the terlipressin-induced depression in mixed-venous oxygen saturation (Svo2) in patients with catecholamine-dependent septic shock. Methods Prospective, randomized, controlled study performed in a university hospital intensive care unit. Septic shock patients requiring a continuous infusion of norepinephrine (0.9 µg kg−1 min−1) to maintain mean arterial pressure (MAP) at 70 (sd 5) mm Hg were randomly allocated to be treated either with (i) sole norepinephrine infusion (control, n=20), (ii) a single dose of terlipressin 1 mg (n=19), or (iii) a single dose of terlipressin 1 mg followed by dobutamine infusion titrated to reverse the anticipated reduction in Svo2 (n=20). Systemic, pulmonary, and regional haemodynamic variables were obtained at baseline and after 2 and 4 h. Laboratory surrogate markers of organ (dys)function were tested at baseline and after 12 and 24 h. Results Terlipressin (with and without dobutamine) infusion preserved MAP at 70 (5) mm Hg, while allowing to reduce norepinephrine requirements to 0.17 (0.2) and 0.2 (0.2) µg kg−1 min−1, respectively [vs1.4 (0.3) µg kg−1 min−1 in controls at 4 h; each P

Obwohl Ultraschall(US)-gesteuerte periphere Nervenkatheter(PNK)-Anlagen zunehmend haufiger angewendet werden, sind die meisten Untersuchungen, in denen US bzw. Nervenstimulator(NS)-gesteuerte PNK verglichen werden, darauf ausgelegt, anasthesierelevante Unterschiede zu detektieren. Es gibt dagegen nur wenige Untersuchungen, in denen patientenrelevante Zielparameter in der postoperativen Phase miteinander verglichen wurden. Diese Analyse verglich die analgetische Effektivitat und die Komplikationsrate von US- vs. NS-gesteuerten PNK zur postoperativen Schmerztherapie. Daten von erwachsenen Patienten (Juni 2006 bis Dezember 2010), die mithilfe von US (nus = 368, 06/2008–12/2010) oder NS (nns = 574, 06/2006–5/2008) gelegten PNK therapiert wurden, wurden retrospektiv analysiert. Neben den demografischen Merkmalen wurden die postoperativen Schmerzintensitaten [“numeric rating scale“ (NRS): 0–10], die Anzahl der Patienten mit zusatzlichem postoperativem Opioidbedarf, der kumulative Lokalanasthetikaverbrauch und die katheterassoziierten Komplikationen erfasst. Patienten, die einen mit einem US gesteuerten PNK erhielten, gaben am Operationstag geringere Schmerzintensitaten in Ruhe (p = 0,034) und bei Belastung (p

Background Optimized anaesthetic management might improve the outcome after cancer surgery. A retrospective analysis was performed to assess the association between spinal anaesthesia (SpA) or general anaesthesia (GA) and survival in patients undergoing surgery for malignant melanoma (MM). Methods Records for 275 patients who required SpA or GA for inguinal lymph-node dissection after primary MM in the lower extremity between 1998 and 2005 were reviewed. The follow-up ended in 2009. Survival was calculated as days from surgery to the date of death or last patient contact. The primary endpoint was mortality during a 10 yr observation period. Results Of 273 patients included, 52 received SpA and 221 GA, either as balanced anaesthesia (sevoflurane/sufentanil, n=118) or as total i.v. anaesthesia (propofol/remifentanil, n=103). The mean follow-up period was 52.2 ( sd 35.69) months after operation. Significant effects on cumulative survival were observed for gender, ASA status, tumour size, and type of surgery (P=0.000). After matched-pairs adjustment, no differences in these variables were found between patients with SpA and GA. A trend towards a better cumulative survival rate for patients with SpA was demonstrated [mean survival (months), SpA: 95.9, 95% confidence interval (CI), 81.2–110.5; GA: 70.4, 95% CI, 53.6–87.1; P=0.087]. Further analysis comparing SpA with the subgroup of balanced volatile GA confirmed this trend [mean survival (months), SpA: 95.9, 95% CI, 81.2–110.5; volatile balanced anaesthesia: 68.5, 95% CI, 49.6–87.5, P=0.081]. Conclusions These data suggest an association between anaesthetic technique and cancer outcome in MM patients after lymph-node dissection. Prospective controlled trials on this topic are warranted.

Medikamentenverwechslungen in der Akutmedizin sind haufig und potenziell todlich. Dies rechtfertigt Investitionen in Patientensicherheit. Unser Ziel war die Entwicklung und Einfuhrung einer auf die Bedurfnisse des Rettungsdienstes zugeschnittenen Vorhaltung von Spritzenaufklebern nach DIVI/ISO 26825. Befragungen von Rettungsfachleuten ergaben den Rahmen fur die Entwicklung: Spritzenaufkleber mussen in handlicher und kompakter Form vorgehalten werden. Bisherige Systeme (Handabroller), die in der Klinik verwendet werden, sind fur die mobile Anwendung im Rettungsdienst zu gros. Daher wurde eine auf die Anforderungen des Rettungsdienstes abgestimmte Vorhaltung entwickelt. Die Spritzenaufkleber werden nun in einem kompakten Ringbuch (DIN A6) vorgehalten. Ein Register erlaubt schnellen Zugriff auf die alphabetisch sortierten Aufkleber. Die Aufkleber bestehen aus Polypropylen und sind reisfest. Sie sind mit Kugelschreiber beschriftbar und kleben auch bei Befeuchtung. Die Lagerfahigkeit betragt 6 Jahre. In einer begleitenden Fortbildung wurden die Mitarbeiter auf die Gefahr von Medikamentenverwechslungen durch fehlende Beschriftungen aufmerksam gemacht. Das Produkt befindet sich seit Marz 2011 im Einsatz und zeigt eine hohe Akzeptanz.

Summary. Background: Protein disulfide isomerase (PDI) controls platelet integrin function, tissue-factor (TF) activation, and concentrates at fibrin and thrombus formation sites of vascular injury. Objective: To investigate the involvement of surface thiol isomerases and especially PDI, in thrombin-mediated thrombin amplification on human platelets. Methods/results: Using a newly developed thrombin-dependent platelet thrombin generation assay, we observed that the feedback activation of thrombin generation on the platelet surface does not depend on TF, as anti-TF antibodies inhibiting TF-induced thrombin formation in platelet-depleted plasma had no effect compared with vehicle-treated controls. Feedback activation of thrombin generation in the presence of platelets was significantly diminished by membrane impermeant thiol blockers or by the thiol isomerase-inhibitors bacitracin and anti-PDI antibody RL90, respectively. Platelet thrombin formation depends on binding of coagulation factors to the platelet surface. Therefore, involvement of thiol isomerases in this binding was investigated. As shown by confocal microscopy and flow cytometry, thrombin-stimulated platelets exhibited increased surface-associated PDI as well as extracellular disulfide reductase activity compared with unstimulated platelets. Flow cytometric analysis revealed that membrane impermeant thiol blockers or PDI inhibitors, which had been added after platelet stimulation and after phosphatidylserine exposure to exclude their influence on primary platelet activation, significantly inhibited binding of all coagulation factors to thrombin-stimulated platelets. Conclusions: Thus, surface-associated PDI is an important regulator of coagulation factor ligation to thrombin-stimulated platelets and of subsequent feedback activation of platelet thrombin generation. Cell surface thiol isomerases might be therefore powerful targets to control hemostasis and thrombosis.

Demografische Entwicklungen und ein verandertes Inanspruchnahmeverhalten der Bevolkerung tragen zu stetig steigenden Notarzteinsatzen bei. In der vorliegenden Untersuchung wurde das unterschiedliche Inanspruchnahmeverhalten in Abhangigkeit vom Sozialstatus analysiert und die Veranderung der Patientenaltersstruktur als weitere Einflussgrose uberpruft. Alle Notarzteinsatze aus 2006 der Stadt Munster wurden den 45 Stadtteilen zugeordnet. Zum Vergleich der Inanspruchnahme des Notarztdienstes mit dem soziookonomischen Status wurden die regionale Einsatzinzidenz der einzelnen Stadtteile (Einsatze/100 Einwohner/Jahr) und der soziookonomische Status anhand der prozentualen Anteile Arbeitsloser und Sozialhilfeempfanger eines Stadtteils berechnet. Der Einsatzschweregrad wurde mithilfe der Munchner-National-Advisory-Committee-for-Aeronautics(M-NACA)-Klassifizierung durch den Notarzt festgelegt. Stadtteile mit niedrigem soziookonomischen Status wiesen eine signifikant hohere Einsatzinzidenz auf, jedoch zeigt sich eine annahernde Gleichverteilung des relativen Anteils an nichtvital bedrohten Patienten. Auserdem konnte ein steigender Anteil an lebensbedrohlichen Einsatzen im hoheren Lebensalter der Patienten nachgewiesen werden. Zwar konnte eine signifikant hohere Einsatzinzidenz in den Stadtteilen mit niedrigem soziookonomischen Status festgestellt werden, die Uberprufung der Einsatzschweregrade in den unterschiedlichen Stadtteilen zeigte jedoch eine annahernde Gleichverteilung. Fur den Bereich der notarztlichen Versorgung lasst sich in diesen Gebieten somit zwar ein erhohtes, jedoch mit der Bedurftigkeitsstruktur korrelierendes Einsatzaufkommen verzeichnen.

The quality of chest compression is a determinant of survival after cardiac arrest. Therefore, the European Resuscitation Council (ERC) 2010 guidelines on resuscitation strongly focus on compression quality. Despite its impact on survival, observational studies have shown that chest compression quality is not reached by professional rescue teams. Real-time feedback devices for resuscitation are able to measure chest compression during an ongoing resuscitation attempt through a sternal sensor equipped with a motion and pressure detection system. In addition to the electrocardiograph (ECG) ventilation can be detected by transthoracic impedance monitoring. In cases of quality deviation, such as shallow chest compression depth or hyperventilation, feedback systems produce visual or acoustic alarms. Rescuers can thereby be supported and guided to the requested quality in chest compression and ventilation. Feedback technology is currently available both as a so-called stand-alone device and as an integrated feature in a monitor/defibrillator unit. Multiple studies have demonstrated sustainable enhancement in the education of resuscitation due to the use of real-time feedback technology. There is evidence that real-time feedback for resuscitation combined with training and debriefing strategies can improve both resuscitation quality and patient survival. Chest compression quality is an independent predictor for survival in resuscitation and should therefore be measured and documented in further clinical multicenter trials.

Neuraxial blockade confers benefits to surgical patients not only due to the high analgesic quality but also through a reduction in postoperative complications, such as respiratory insufficiency and a shortening of postoperative paralytic ileus. In orthopedic surgery peripheral and neuraxial blockades are extensively used to enhance postoperative mobilization. The most serious complication of neuraxial blockade is spinal epidural hematoma, which may lead to permanent paraplegia if left untreated. The risk is enhanced in patients receiving thromboembolism prophylaxis. Most national societies have issued guidelines with specific time intervals between application of antithrombotic drugs and subsequent neuraxial blockade to minimize this risk. From the viewpoint of an anesthesiologist it is preferable to start with chemical thromboembolism prophylaxis postoperatively as opposed to preoperatively, to administer all drugs in the evening and to limit the number of available drugs at each site. The safety of neuraxial blockade in the presence of the new oral anticoagulant rivaroxaban is currently unknown due to limited experience and dabigatran is considered contraindicated with indwelling epidural catheters according to the manufacturer.

Background Perioperative hypothermia has been reported to increase the occurrence of cardiovascular complications. By increasing the activity of sympathetic nervous system, perioperative hypothermia also has the potential to increase cardiac injury and dysfunction associated with subarachnoid hemorrhage. Methods The Intraoperative Hypothermia for Aneurysm Surgery Trial randomized patients undergoing cerebral aneurysm surgery to intraoperative hypothermia (n = 499, 33.3 degrees +/- 0.8 degrees C) or normothermia (n = 501, 36.7 degrees +/- 0.5 degrees C). Cardiovascular events (hypotension, arrhythmias, vasopressor use, myocardial infarction, and others) were prospectively followed until 3-month follow-up and were compared in hypothermic and normothermic patients. A subset of 62 patients (hypothermia, n = 33; normothermia, n = 29) also had preoperative and postoperative (within 24 h) measurement of cardiac troponin-I and echocardiography to explore the association between perioperative hypothermia and subarachnoid hemorrhage-associated myocardial injury and left ventricular function. Results There was no difference between hypothermic and normothermic patients in the occurrence of any single cardiovascular event or in composite cardiovascular events. There was no difference in mortality (6%) between groups, and there was only a single primary cardiovascular death (normothermia). There was no difference between hypothermic and normothermic patients in postoperative versus preoperative left ventricular regional wall motion or ejection fraction. Compared with preoperative values, hypothermic patients had no postoperative increase in cardiac troponin-I (median change 0.00 microg/l), whereas normothermic patients had a small postoperative increase (median change + 0.01 microg/l, P = 0.038). Conclusion In patients undergoing cerebral aneurysm surgery, perioperative hypothermia was not associated with an increased occurrence of cardiovascular events.

Background and purpose: While remifentanil can be used either during labour or fetal surgery, more should be known about the transplacental transfer of this opioid. The aim of this study was to investigate the placental transfer and haemodynamic effects of remifentanil after i.v. administration to pregnant ewes. Experimental approach: Seven pregnant ewes received a continuous infusion of remifentanil (0.33 µg·kg−1·min−1) for 1 h, and maternal and fetal arterial blood samples were drawn at regular intervals during and up to 1 h after the discontinuation of the infusion. Haemodynamic parameters were monitored continuously. Blood gas samples were drawn at baseline and once during the infusion. Key results: Peak maternal remifentanil plasma levels of 4.0 ± 0.9 ng·mL−1 (mean ± SD) and peak fetal plasma levels of 0.4 ± 0.3 ng·mL−1 were obtained. Remifentanil plasma levels dropped rapidly after the discontinuation of the infusion. The continuous infusion of remifentanil did not result in significant maternal or fetal haemodynamic changes. Conclusions and implications: Remifentanil rapidly passes through the placenta of pregnant ewes and although remifentanil concentrations stay significantly lower in the fetus compared with those in the mother, remifentanil can be detected in significant amounts in the fetus.

Hintergrund Das Outcome der kardiopulmonalen Reanimation hangt auch von der Qualitat der Thoraxkompression ab. Obwohl die aktuellen Leitlinien des European Resuscitation Council (ERC) 2005 die technische Entwicklung von Feedback-Systemen fordern, sind bisher keine zufriedenstellenden Ergebnisse zur Anwendung dieser Systeme in der Literatur zu finden.

SummaryInflammation and thrombosis, two processes influencing each other, are involved in the pathogenesis of cerebrovascular disease. We showed that in patients with acute ischaemic stroke circulating platelets are activated and exhausted. To identify whether activated haemostasis might be cause or effect, we investigated the role of leukocyte and platelet activation in patients with severe asymptomatic and symptomatic carotid artery disease. Flow cytometry analysis demonstrated that monocytes from symptomatic (acute stroke aetiology) and asymptomatic patients were highly activated, shown by significantly enhanced presentation of inflammatory markers CD11b and thrombospondin-1 (TSP-1) on the surface. Both correlated positively with monocyte-platelet association rate. However, increased monocyte activation and elevated levels of monocyte-platelet associates in asymptomatic patients were restricted to patients with echo-lucent plaques, providing a close link between monocyte activation and plaque morphology. Circulating single as well as monocyte-bound platelets from symptomatic patients showed significantly enhanced surface expression of P-selectin and TSP-1, whereas platelets from asymptomatic patients were not significantly activated. These results indicate that monocytes activated by inflammation rather than platelets might be the candidates to initiate platelet-monocyte rosetting during the pathogenesis of atherothrombotic cerebral ischaemia and that haemostasis might be activated secondarily by the first occurring inflammation.

Background Although hypothermia and barbiturates improve neurologic outcomes in animal temporary focal ischemia models, the clinical efficacy of these interventions during temporary occlusion of the cerebral vasculature during intracranial aneurysm surgery (temporary clipping) is not established. Methods A post hoc analysis of patients from the Intraoperative Hypothermia for Aneurysm Surgery Trial who underwent temporary clipping was performed. Univariate and multivariate logistic regression methods were used to test for associations between hypothermia, supplemental protective drug, and short- (24-h) and long-term (3-month) neurologic outcomes. An odds ratio more than 1 denotes better outcome. Results Patients undergoing temporary clipping (n = 441) were assigned to intraoperative hypothermia (33.3 degrees +/- 0.8 degrees C, n = 208) or normothermia (36.7 degrees +/- 0.5 degrees C, n = 233), with 178 patients also receiving supplemental protective drug (thiopental or etomidate) during temporary clipping. Three months after surgery, 278 patients (63%) had good outcome (Glasgow Outcome Score = 1). Neither hypothermia (P = 0.847; odds ratio = 1.043, 95% CI = 0.678-1.606) nor supplemental protective drug (P = 0.835; odds ratio = 1.048, 95% CI = 0.674-1.631) were associated with 3-month Glasgow Outcome Score. The effect of supplemental protective drug did not significantly vary with temperature. The effects of hypothermia and protective drug did not significantly vary with temporary clip duration. Similar findings were made for 24-h neurologic status and 3-month Neuropsychological Composite Score. Conclusion In the Intraoperative Hypothermia for Aneurysm Surgery Trial, neither systemic hypothermia nor supplemental protective drug affected short- or long-term neurologic outcomes of patients undergoing temporary clipping.

The aim of this study was to find the fastest, easiest and safest method of achieving orotracheal intubation for general anaesthesia in laboratory pigs. Twenty-one Yorkshire × Landrace crossbreed male castrated pigs (32.9 ± 4.8 kg) were investigated. Dorsal and ventral recumbency are the alternatives most frequently described for animal positioning during intubation procedures. Based on standardized induction of general anaesthesia using pentobarbital and remifentanil, the dorsoventral and ventrodorsal positions were compared with regard to the time needed, changes in oxygenation and circulatory response. Positioning was found to be crucial for fast orotracheal intubation. The time required for safe intubation is significantly shorter with the ventrodorsal position (17.3 s) in comparison with the dorsoventral position (58.4 s; P < 0.001). Hypoxia did not occur in either group. A significant drop in systolic blood pressure was observed in both groups. Diastolic and mean arterial pressures were not influenced by intubation. A significant increase in heart rate was observed in pigs intubated in ventral recumbency, but not after intubation in the dorsal position. Preoxygenation before intubation is vitally important for preventing hypoxia. With regard to clinical practice, the haemodynamic changes observed in this investigation do not appear to be relevant, as the mean arterial pressure was not altered and heart rates only increased moderately. It may be concluded that the ventrodorsal position can be recommended for orotracheal intubation in pigs as the first choice for providing a smooth and fast airway.

Die intravenose patientenkontrollierte Analgesie (i.v.-PCA) gilt als Therapiestandard der parenteralen postoperativen Schmerztherapie, weil die Patienten die erforderliche Analgetikadosis selbst titrieren. Iontophoretische patientenaktivierte transdermale Systeme (IPATS) stellen eine neue, nichtinvasive vorprogrammierte Therapieform dar, die nur einen geringen apparativen Aufwand erfordert. Nach Drucken des Patienten auf einen in die nur kreditkartengrosen Gerate eingelassenen Knopf transportieren sie einen Bolus von 40 µg Fentanyl uber 10 min mithilfe der Iontophorese durch die intakte Haut. Mehrere randomisierte kontrollierte Vergleichsstudien zeigen, dass IPATS genauso wirksam und effektiv sind wie die i.v.-PCA mit Morphin. Die Systeme stellen eine neue Methode der postoperativen Schmerztherapie dar, die die Mobilitat der Patienten erhoht, den Versorgungsaufwand vermindert und das Risiko von Programmierungsfehlern reduziert. In dieser Ubersichtsarbeit zu IPATS wird ein Uberblick uber Wirksamkeit, Pharmakokinetik, Handhabung und Prozesskostenokonomie gegeben.

Background and objectives In Germany there is considerable variability in the organizational forms of intensive-care medicine. We present economical data that arose during the reorganization of an intensive care unit with the implementation of the continuous presence of a trained intensivist. The unit was changed from an intensive-observational unit managed by four surgical departments without continuous presence of a trained intensivist to an interdisciplinary surgical intensive care unit managed by the Department of Anaesthesia in co-operation with the surgical departments with the continuous presence of trained intensivists. Methods Measurement of costs for personnel, medical equipment and external services, revenues, length of hospital stay and complications of cardiac surgical patients. Results Per year costs for personnel increased by approximately euro240,000, while expenses for medical equipment were reduced by euro245,000. In all, 466 hospital days were saved by the reduction in the length of hospital stay, providing capacity for 22 additional cardiac surgical cases. In addition, the presence of trained intensivists made it possible to provide care for more severely ill patients, which gained approximately 100 additional case-mix points and increased the hospital's revenues by more than euro300,000. Emergency readmission to the intensive care unit was reduced by 17%. The number of patients requiring renal replacement therapy and those developing non-occlusive mesenteric ischaemia was substantially reduced. Conclusion In addition to the medical advantages, staffing the intensive care unit with trained intensivists 24 h a day was of appreciable economical benefit.

Background. Hypodynamic septic shock is associated with a poor prognosis. The present randomized-controlled laboratory experiment was designed to test the hypothesis that the vasodilatory peptide hormone adrenomedullin (ADM) is a useful agent to prevent and reverse the development of hypodynamic circulation in ovine endotoxaemia. Methods. Twenty-four healthy ewes were chronically instrumented for haemodynamic monitoring and randomly allocated to either the control, treatment, or prophylaxis group (n¼8 each). After a baseline (BL) measurement in the healthy state, all sheep were subjected to a continuous endotoxin infusion started at 10 ng kg 21 min 21 and doubled every hour six times. After 4 h of endotoxin challenge, the treatment group received ADM (50 ng kg 21 min 21 ) for the remaining 3 h of the experiment. The prophylaxis group received a simultaneous infusion of endotoxin and ADM (50 ng kg 21 min 21 ) from the beginning to the end of the 7 h intervention period. Results. In the control and treatment groups, the ewes exhibited a hypodynamic circulation at 4h( .20% reduction in cardiac index, both P,0.01 vs BL). Endotoxin also increased mean pulmonary arterial pressure (MPAP) and arterial lactate concentrations. Prophylactic infusion of ADM prevented the occurrence of pulmonary hypertension and hypodynamic circulation and thereby blunted the increase in arterial lactate concentrations. In the treatment group, ADM administration increased CI (P,0.001) and reduced both MPAP (P¼0.023) and arterial lactate concentrations (P,0.001 each at 7 h) when compared with the control group. Conclusions. This study demonstrates that exogenous ADM prevents and reverses hypodynamic circulation, attenuates pulmonary hypertension, and limits lactic acidosis in ovine endotoxaemia.

Summary The still ever increasing demand for sedation and/or analgesia for diagnostic and therapeutic procedures puts high pressure on anaesthesia care providers all over Europe. Since the capacity to provide that service by anaesthetists is limited in most European countries, guidelines for non-anaesthetist doctors who want to sedate patients on a high-quality level and especially in a safe way are mandatory. This paper, produced by a working party of the European Board of Anaesthesiology of the European Union of Medical Specialists (EUMS/UEMS), gives direction to those practitioners who feel responsibilities in this area of medicine. Close cooperation with anaesthesiologists seems mandatory to achieve and sustain a high-quality standard for our patients undergoing medical or surgical procedures under sedation.

Ruckenmarknahe Regionalanasthesien konnen neben einer guten Schmerzlinderung die perioperative Morbiditat und Mortalitat senken, sind aber nicht ohne Risiken. Neben motorischen Blockaden und Juckreiz kann als schwerwiegendste Komplikation ein spinales epidurales Hamatom auftreten. Ohne eine sofortige operative Entlastung kann hieraus eine bleibende Querschnittslahmung resultieren. Die Inzidenz wird je nach Patientenklientel mit 1:3600 bis 1:200.000 angegeben. Risikofaktoren fur Hamatome sind neben punktionsbedingten Faktoren vor allem die gleichzeitige Therapie mit Antithrombotika oder eine beeintrachtigte Gerinnung. Aus diesem Grund wurden weltweit Leitlinien herausgegeben, die Sicherheitsabstande zwischen der Gabe von Antithrombotika und einer ruckenmarknahen Punktion fordern, um eine Punktion zum Zeitpunkt von Talspiegeln zu gewahrleisten. Sind solche Zeitabstande aufgrund eines erhohten Risikos von thrombembolischen Komplikationen nicht einzuhalten, so sollte auf eine ruckenmarknahes Regionalanasthesieverfahren verzichtet werden und alternativ eine andere Form der Analgesie oder eine periphere Nervenblockade durchgefuhrt werden. Bei Patienten, bei denen aufgrund einer Stentimplantation die Gabe von Acetylsalicylsaure auch perioperativ weitergegeben werden sollte, kann unter sorgfaltiger Nutzen-Risiko-Analyse eine ruckenmarknahe Punktion durchgefuhrt werden, wenn auf eine gleichzeitige Thrombembolieprophylaxe verzichtet wird.

Pain after surgery continues to be undermanaged. Studies and initiatives aiming to improve the management of postoperative pain are growing; however, most studies focus on inpatients and pain on the first day after surgery. The management of postoperative pain after ambulatory surgery and for several days thereafter is not yet a major focus. One reason is the low return rate of the questionnaires in the ambulatory sector. This article reports the development and feasibility of a web-based electronic data collection system to examine pain and pain-related outcome on predefined postoperative days after ambulatory surgery.In this prospective pilot study 127 patients scheduled for ambulatory surgery were asked to participate in a survey to evaluate aspects related to pain after ambulatory surgery. The data survey was divided in (1) a preoperative, intraoperative and postoperative part and (2) a postoperative internet-based electronic questionnaire which was sent via e-mail link to the patient on days 1, 3 and 7 after surgery. A software was developed using a PHP-based platform to send e-mails and retrieve the data after web-based entries via a local browser. Feasibility, internet-based hitches and compliance were assessed by an additional telephone call after day 7.A total of 100 patients (50 female) between 18 and 71 years (mean 39.1 ± 12.7 years) were included in the pilot study. Return rates of the electronic questionnaires were 86% (days 3 and 7) and 91% (day 1 after surgery). All 3 electronic questionnaires were answered by 82% of patients. Aspects influencing the return rate of questionnaires were work status but not age, gender, education level and preoperative pain. Telephone interviews were performed with 81 patients and revealed high operability of the internet-based survey without any major problems.The user-friendly feasibility and operability of this internet-based electronic data survey system explain the high compliance and return rate of electronic questionnaires by patients at home after ambulatory surgery. This survey tool therefore provides unique opportunities to evaluate and improve postoperative pain management after ambulatory surgery.

Acute kidney injury (AKI) is a common complication after cardiac surgical procedures and is associated with an increased morbidity and mortality.

Patients with head and neck cancer (HNC) are at risk for undernutrition. Dietary counseling during treatment has positive effects on nutritional status and quality of life, however, the effects of dietary counseling started before initiation of treatment are currently unknown. Therefore we assessed the effect of early individualized dietary counseling (DC) on weight loss, major complications, and length of hospital stay (LOS) in patients with HNC. Ninety-five newly diagnosed HNC patients with (risk of) undernutrition receiving DC were compared to 95 matched HNC patients receiving usual nutritional care (UC). Difference in weight change over time was analyzed by generalized estimating equations (GEE). Differences in complications and LOS were studied by Pearson chi-squared and student's t-tests. Weight change between diagnosis and end of treatment was -6.0 ± 6.9% (DC) and -5.4 ± 5.7% (UC; GEE: -0.4kg, 95% confidence interval: -1.2 to 0.5; P = 0.44). Less DC patients experienced overall postoperative complications (44%/70%, P = 0.04). No effect on major postoperative or (chemo)radiotherapy complications or LOS was found. This study showed a lower prevalence of overall postoperative complications in HNC patients receiving DC but could not demonstrate an effect on weight loss, other complications, and LOS.

Ketamine is the only intravenous anesthetic that causes an increase in mean arterial pressure without compromising cardiac output. These beneficial effects are basically linked to stimulation of the sympathetic nervous system, inhibition of adenosine triphosphate-sensitive potassium channels and interactions with the nitric oxide pathway. Experimental and clinical studies have shown that ketamine exerts antiinflammatory properties by inhibiting the release of proinflammatory cytokines, such as tumor necrosis factor-alpha and interleukin-6. In addition, there is increasing evidence that early ketamine administration reduces mortality in experimental sepsis models. In view of the current literature ketamine appears to represent a beneficial therapeutic option for long-term sedation of patients with arterial hypotension resulting from sepsis and systemic inflammatory response syndrome (SIRS). However, it has to be taken into account that ketamine inhibits endothelial nitric oxide synthase, thereby potentially aggravating impaired (micro) regional blood flow in sepsis. Future studies are required to investigate the role of ketamine in the treatment of patients with sepsis and SIRS.

Acute respiratory distress syndrome (ARDS) is a common, devastating clinical problem arising from a number of conditions, such as pneumonia, trauma or sepsis. Because of its significant mortality and morbidity, ARDS has been in the focus of extensive experimental and clinical research. Since there is little doubt that alterations of the surfactant system contribute to lung dysfunction and the onset of ARDS, several clinical studies examined the therapeutic safety and efficacy of a surfactant replacement therapy. Clinical experience with exogenous surfactant has proven inconsistent as a therapeutic modality for adult patients with ARDS. This is mainly due to a number of confounding factors, e.g. severity of injury at the time of treatment, dosing regimes and delivery methods used in different trials. However, current data suggest that patients with direct ARDS (e.g. pneumonia, aspiration) could benefit from surfactant replacement therapy rather than patients with indirect ARDS (e.g. sepsis, trauma). Although surfactant replacement therapy has been shown to significantly reduce mortality in neonates with ARDS, there has been no large randomised clinical trial showing that exogenous surfactant improves outcome in adults with respiratory failure. Therefore, surfactant therapy cannot be recommended for routine clinical use in adult patients and has to be considered as a last resort treatment.

Adrenomedullin (AM) is an endogenous vasodilatory peptide hormone, which plays a key role in the regulation and preservation of cardiovascular and pulmonary functions. Clinical and experimental studies have demonstrated that AM represents an alternative therapeutic option in the treatment of pulmonary hypertension. In addition, AM proved to be useful in the treatment of cardiovascular dysfunctions, such as arterial hypertension and congestive heart failure following myocardial infarction. Recent research has also shown that AM plays a pivotal role in the development of sepsis-associated hemodynamic and microcirculatory disorders. Experimental studies also suggest that infusion of exogenous AM might be a rational approach to prevent and treat hypodynamic septic shock. The objectives of this review article are to characterize the regulative properties of AM and to discuss clinical and experimental studies which allow to judge the role of AM in the setting of cardiovascular dysfunction and sepsis.

Background. Impedance cardiography (ICG) has been used extensively to estimate stroke volume (SV) and cardiac output (CO) from changes of thoracic electrical bioimpedance (TEB). However, studies comparing ICG with reference methods have questioned the reliability of this approach. Electrical velocimetry (EV) provides a new algorithm to calculate CO from variations in TEB. As the transoesophageal Doppler echocardiographic quantification of CO (TOE‐CO) has emerged as a reliable method, the purpose of this study was to determine the limits of agreement between CO estimations using EV (EV‐CO) and TOE‐CO. Methods. Standard ECG electrodes were used for non-invasive EV‐CO measurements. These were placed on 37 patients scheduled for coronary artery surgery necessitating transoesophageal echocardiography monitoring. Simultaneous EV‐CO and TOE‐CO measurements were recorded after induction of anaesthesia. EV‐CO was calculated using the Bernstein‐Osypka equation. TOE‐CO was measured across the aortic valve using continuous-wave Doppler echocardiography and a triangular orifice model. Results. A significant high correlation was found between the TOE‐CO and the EV‐CO measurements (r 2 =0.86). Data were related linearly. The slope of the line (1.10 (SE 0.07)) was not significantly different from unity, and the point at which it intersected the ordinate (� 0.46 (0.32) litre min � 1 ) was not significantly different from zero. Bland‐Altman analysis revealed a bias of 0.18 litre min � 1 with narrow limits of agreement (� 0.99 to 1.36 litre min � 1 ). Conclusions. The agreement between EV‐CO and TOE‐CO is clinically acceptable, and these two techniques can be used interchangeably.

The treatment of critically ill patients has advanced markedly over the last decade. However, non-surgical bleeding of a diffuse nature from numerous tiny capillaries still remains a challenge. Once initiated, this type of bleeding may be troublesome and a vicious circle develops since it is not a single vessel contributing to this blood loss. The description 'non-surgical blood loss' is often given to this. This review describes a step-by-step approach for the treatment of non-surgical bleeding and includes various measures, such as desmopressin, blood components, antifibrinolytics, antithrombin III, prothrombin complex concentrates and factor XIII. While most non-surgical bleedings can be managed using the approach described here, a number of patients still continue to bleed. In these cases, the surgeon should re-evaluate the bleeding in terms of its surgical origin. If this can positively be excluded and if all of measures described fail to reduce or stop the bleeding, further treatment of such uncontrolled bleeding remains symptomatic.

ObjectivesWe sought to evaluate the efficacy of recombinant human antithrombin III for restoration of heparin responsiveness in heparin-resistant patients scheduled for cardiac surgery.MethodsThis was a multicenter, randomized, double-blind, placebo-controlled study in heparin-resistant patients undergoing elective cardiac surgery. Patients were considered heparin resistant if the activated clotting time was less than 480 seconds after 400 U/kg heparin. Fifty-two heparin-resistant patients were randomized into 2 cohorts. One cohort received a single bolus (75 U/kg) of recombinant human antithrombin III (n = 28), and the other, the placebo group (n = 24), received a normal saline bolus. If the activated clotting time remained less than 480 seconds, this was defined as treatment failure, and 2 units of fresh frozen plasma were transfused. Patients were monitored for adverse events during hospitalization.ResultsSix (21%) of the patients in the recombinant human antithrombin III group received fresh frozen plasma transfusions compared with 22 (92%) of the placebo-treated patients (P < .001). Two units of fresh frozen plasma did not restore heparin responsiveness. There was no increased incidence of adverse events associated with recombinant human antithrombin III administration. Postoperative 24-hour chest tube bleeding was not different in the 2 groups. Surrogate measures of hemostatic activation suggested that there was less activation of the hemostatic system during cardiopulmonary bypass in the recombinant human antithrombin III group.ConclusionTreatment with recombinant human antithrombin III in a dose of 75 U/kg is effective in restoring heparin responsiveness and promoting therapeutic anticoagulation for cardiopulmonary bypass in the majority of heparin-resistant patients. Two units of fresh frozen plasma were insufficient to restore heparin responsiveness. There was no apparent increase in bleeding associated with recombinant human antithrombin III.

Vasopressin und Terlipressin werden zunehmend als alternative non-adrenerge Vasopressoren in der Kreislauftherapie bei septischen Patienten mit arterieller Hypotonie eingesetzt. Neben ihrem hervorragenden vasopressorischen Effekt vermogen Vasopressin-Analoga jedoch die Makrohamodynamik, das Sauerstoffangebot und den mikrovaskularen Blutfluss negativ zu beeinflussen. Durch diese Effekte konnen Vasopressin und Terlipressin die Organfunktion moglicherweise kompromittieren und potenziell zur Entwicklung eines Multiorganversagens beitragen. Im Folgenden werden tierexperimentelle und klinische Studien diskutiert, die eine Aussage zur Wirkung von Vasopressin und Terlipressin auf Mikrozirkulation, Sauerstofftransport, Metabolismus und Organfunktion bei Patienten mit Sepsis und systemischen Entzundungsreaktionen („systemic inflammatory response syndrome“, SIRS) erlauben. Obwohl Vasopressin-Analoga vielversprechende Alternativen zur Therapie der katecholaminrefraktaren arteriellen Hypotension darstellen, kann bislang keine eindeutige Empfehlung zur Verwendung in dieser Indikation ausgesprochen werden, da es keine prospektive Studie gibt, in der durch den Einsatz von Vasopressin-Rezeptoragonisten ein verbessertes Outcome erzielt wurde.

Intestinale Perfusionsstorungen stellen wegen der geringen Hypoxietoleranz des Darmes eine schwere Erkrankung hoher Mortalitat dar. Sie begegnen dem perioperativ tatigen Intensivmediziner im Zusammenhang mit anderen schweren Grunderkrankungen, als Folge chirurgischer Eingriffe, unter Medikamentengabe oder invasiver Therapie mit organersetzenden Verfahren. Von zunehmender intensivmedizinischer Bedeutung ist die nonokklusive Form der mesenterialarteriellen Ischamie (NOMI). Aufgrund der reduzierten Symptomatik bei Intensivpatienten erfordert sie eine erhohte Aufmerksamkeit. Entscheidend fur die Prognose ist die fruhzeitige Diagnose. Der Ubersichtsartikel stellt neben der Pathophysiologie die Diagnostik und das Spektrum therapeutischer sowie praventiver Masnahmen vor.

Introduction:Maternal hypotension is a major concern in obstetric anesthesia, and concerns have been raised about standard vasopressor therapy with ephedrine. Therefore, we evaluated the maternal and fetal hemodynamic effects of two potential alternatives to ephedrine. Methods: Hypotension was induced by epidural administration of lidocaine in 6 chronically instrumented pregnant ewes (at 118–122 days of gestation, term 145 days). Three treatments were studied: 25 mg ephedrine, 5 mg etilefrine and 100 mg cafedrine/5 mg theodrenaline (C/T) intravenously. Mean fetal and maternal blood pressure and heart rate, uterine blood flow, as well as fetal and maternal arterial blood gases were recorded for 60 min. Results:All three vasopressors increased maternal blood pressure, accompanied by a significant increase in uterine blood flow. C/T caused marked maternal tachycardia, whereas ephedrine decreased maternal heart rate. Maternal and fetal blood gases did not change during any of the three treatment regimens. Conclusion:All three vasopressors restored maternal blood pressure and uterine blood flow after epidurally induced maternal hypotension. However, restoration of uterine perfusion was delayed and less pronounced with C/T.

Background: Chronically compromised uterine perfusion may lead to placental insufficiency and subsequent intrauterine growth restriction (IUGR). Various therapeutic approaches (e.g. vasodilators, low-dose aspirin, intravenous glucose infusion, and hemodilution) are often of limited efficacy. Local anesthetics have been shown to improve placental blood flow in pre-eclamptic women. We hypothesized that epidural administration of local anesthetics might improve outcome in IUGR independent of the underlying cause. In preparation for a clinical trial to test this hypothesis, we performed a pilot study in 10 patients. Methods: After approval of the study protocol, 10 pregnant women presenting with oligohydramnios and IUGR were included in the study. In addition to our standard protocol (magnesium, glucose, betamethasone), each patient received an epidural catheter (T10/T12) with continuous infusion of bupivacaine 0.175% at a rate of 5 ml/h. Uteroplacental circulation was monitored by Doppler sonography and the amount of amniotic fluid was estimated daily. Results: Epidural insertion and infusion was performed without complications. Four patients continued to deteriorate rapidly, amniotic fluid volume did not change and uterine artery pulsatility index (PI) tended to increase. In the remaining 6 patients the clinical status stabilized, amniotic fluid volume tended to increase and uterine artery PI tended to decrease during treatment. This improvement was associated with a prolonged interval to cesarean section and increased infant birth weight. Conclusion: Our data suggest that, even if the underlying cause of IUGR is not pre-eclampsia, epidural local anesthetic administration might improve placental blood flow and be beneficial in a subgroup of patients. A clinical trial to test this hypothesis appears warranted.