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Systemic mycoses, especially pulmonary diseases and septicemia are observed increasingly at intensive care units. Essential risk factors for development of candidosis are the expanded use of antibiotics and immunocompromised patients, caused either as a result of a severe underlying disease or iatrogenically induced after organ transplantation. Candida albicans is the most frequent pathogen in microbiological findings. Blood cultures are only positive in massive fungemia. We report a 50-year-old patient with recurrent Candida-septicemia: rupture of the distal esophagus after dilatation because of cardiac achalasia with mediastinal emphysema and mediastinitis. Severe acute respiratory distress syndrome after aspiration with septic shock and acute renal failure at the beginning. Long-term mechanical ventilation, continuous renal replacement therapy and multifarious antibiotic therapy. Early microbiological samples of several positive blood cultures and bronchoalveolar lavages revealed the presence of Candida albicans. In the further clinical course, detection of Pseudomonas species in bronchoalveolar lavages and Staphylococci as well as Enterococci in a number of positive blood cultures. Later on development of a severe liver dysfunction with test results that showed an intrahepatic cholestasis. Because of coagulation failure commencement of artificial liver support with the MARS-system (molecule adsorbent recirculating system). Decrease of high bilirubin levels was accompanied by improvement of clinical condition of the patient. In the following course, repeated severe systemic infections with phases of septicemia or rather septic shock and detection of Candida in several positive blood cultures and bronchoalveolar lavages. In each case increasing bilirubin levels with signs of intrahepatic cholestasis and each time improvement with antimycotic therapy (voriconazol, caspofungin and fluconazol). The patient showed more and more signs of immunodeficiency in the sequel. The clinical appearance of candidosis is manifold. Systemic Candida infections are frequent in patients with immunodeficiency. A recurrent Candida septicemia with prolonged respiratory failure and severe liver dysfunction in form of cholestatic hepatosis, that improved several times with antimycotic therapy in combination with evidence based intensive care measures and artificial organ support is a comparatively rare event.

In obstructive defecation syndrome (ODS) combinations of morphologic alterations of the pelvic floor and the colorectum are nearly always evident. Laparoscopic resection rectopexy (LRR) aims at restoring physiological function. We present the results of 19 years of experience with this procedure in patients with ODS.Between 1993 and 2012, 264 patients underwent LRR for ODS at our department. Perioperative and follow-up data were analyzed.The female/male ratio was 25.4:1, mean age was 61.3 years (±14.3 years), and mean body mass index (BMI) was 25.2 kg/m(2) (±4.2 kg/m(2)). The pathological conditions most frequently found in combination were a sigmoidocele plus a rectocele (n = 79) and a sigmoidocele plus a rectal prolapse or intussusception (n = 69). The conversion rate was 2.3 % (n = 6). The mortality rate was 0.75 % (n = 2), the rate of complications requiring surgical re-intervention was 4.3 % (n = 11), and the rate of minor complications was 19.8 % (n = 51). Follow-up data were available for 161 patients with a mean follow-up of 58.2 months (±47.1 months). Long-term results showed that 79.5 % of patients (n = 128) reported at least an improvement of symptoms. In cases of a sigmoidocele (n = 63 available for follow-up) or a rectal prolapse II°/III° (n = 72 available for follow-up), the improvement rates were 79.4 % (n = 50) and 81.9 % (n = 59), respectively.LRR is a safe and effective procedure. Our perioperative results and long-term functional outcome strengthen the evidence regarding benefits of LRR in patients with an outlet obstruction. However, careful patient selection is essential.

Zygomycosis caused by Rhizopus species is an aggressive and rapidly progressive opportunistic fungal infection in immunocompromised patients. It comprises mucocutaneous, rhinocerebral, pulmonary, urological and disseminated infections. Predisposing factors are immunosuppression owing to severe diseases, immunological defects or metabolic disturbances like diabetic ketoacidosis. Rhizopus infections are characterized by angioinvasive growth, necroses of infected tissue and perineural invasion. The histopathologic demonstrable invasion of blood vessels is remarkable for a fungal infection. The mortality of zygomycosis is very high, especially for disseminated disease and when immunosuppression cannot be corrected. We report about two cases of pulmonary zygomycosis, caused by Rhizopus spp.: patient 1, female 73 years old: Delayed clinical course according to hip arthroplasty infection and infection of a femoropopliteal bypass of the right leg, eventually exarticulation of the right hip joint, Pseudomonas pneumonia, severe sepsis caused by staphylococci, acute respiratory distress syndrome (ARDs), acute renal failure and multiple use of antibiotics. Subsequently detection of Rhizopus spp. in the bronchoalveolar lavage and treatment with amphotericin B for this reason. Patient 2, male 68 years old: transplantation of kidney in past medical history, presenting with acute renal failure and with quite a few infections before. In the sequel development of abscessing pneumonia on the right side with a pleural empyema. Rhizopus spp. were detected by microbiological testing in the empyema fluid. These findings required surgical intervention, resection of the lower lobe of the right lung and within the same operation of the renal graft because of rejection. The patient was treated with caspofungin. The further course was delayed by several septic phases. Both patients died later on in spite of all efforts. The very rarely seen pulmonary zygomycosis caused by infection with Rhizopus spp. developed in both patients owing to immunosuppression, in one patient iatrogenically induced by immunosuppressive drugs after organ transplantation, in the other as a result of prolonged severe sepsis. In comparison with other mycoses treatment of Rhizopus infections remains difficult. The affinity to blood vessels, where the fungi multiply, and their feature of vascular invasion with thrombosis and infarction complicate therapeutic efforts.

Systemic mycoses, especially pulmonary diseases and septicemia are observed increasingly at intensive care units. Essential risk factors for development of candidosis are the expanded use of antibiotics and immunocompromised patients, caused either as a result of a severe underlying disease or iatrogenically induced after organ transplantation. Candida albicans is the most frequent pathogen in microbiological findings. Blood cultures are only positive in massive fungemia. We report a 50-year-old patient with recurrent Candida-septicemia: rupture of the distal esophagus after dilatation because of cardiac achalasia with mediastinal emphysema and mediastinitis. Severe acute respiratory distress syndrome after aspiration with septic shock and acute renal failure at the beginning. Long-term mechanical ventilation, continuous renal replacement therapy and multifarious antibiotic therapy. Early microbiological samples of several positive blood cultures and bronchoalveolar lavages revealed the presence of Candida albicans. In the further clinical course, detection of Pseudomonas species in bronchoalveolar lavages and Staphylococci as well as Enterococci in a number of positive blood cultures. Later on development of a severe liver dysfunction with test results that showed an intrahepatic cholestasis. Because of coagulation failure commencement of artificial liver support with the MARS-system (molecule adsorbent recirculating system). Decrease of high bilirubin levels was accompanied by improvement of clinical condition of the patient. In the following course, repeated severe systemic infections with phases of septicemia or rather septic shock and detection of Candida in several positive blood cultures and bronchoalveolar lavages. In each case increasing bilirubin levels with signs of intrahepatic cholestasis and each time improvement with antimycotic therapy (voriconazol, caspofungin and fluconazol). The patient showed more and more signs of immunodeficiency in the sequel. The clinical appearance of candidosis is manifold. Systemic Candida infections are frequent in patients with immunodeficiency. A recurrent Candida septicemia with prolonged respiratory failure and severe liver dysfunction in form of cholestatic hepatosis, that improved several times with antimycotic therapy in combination with evidence based intensive care measures and artificial organ support is a comparatively rare event.

In einer prospektiven Studie wurde der Zusammenhang zwischen dem Verlauf der APACHE-II-Score und dem Uberleben bzw. der In–Unit–Mortalitat bei 647 konsekutiven Patienten auf einer chirurgischen Intensivstation untersucht. Mit einer linearen Regressionsanalyse wurden die individuellen Score-Verlaufe der n=4 8 verstorbenen und die einer gleich grosen reprasentativen Stichprobe von den uberlebenden Patienten ausgewertet. Die lineare Regressionsanalyse der individuellen Score–Verlaufe der uberlebenden (m ± SEM : – 5,47 ± 0,80) und verstorbenen (m ± SEM:1,52 ±0,61) Patienten zeigt einen signifikanten Unterschied der Steigungen (p=0,05). Ein Anstieg des APACHE-II-Score im Verlauf einer Intensivtherapie kann schon fruhzeitig auf eine ungunstige Prognose hindeuten, wahrend ein deutlicher Abfall der Werte im Verlauf eher auf ein positives Outcome hindeutet.

Evolution of hemodynamic monitoring revealed many septic shock patients on high catecholamines without proper fluid loading before. The aim of our study was to show that it is possible in quite a few cases to reduce these agents by a forced volume resuscitation combined with active reduction of catecholamines.

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

In acute respiratory failure (ARF), in particular acute lung injury (ALI) and respiratory distress syndrome (ARDS), an intervention in the form of rotational therapy (RT) or the prone position (PP) may improve oxygenation by recruiting alveoli situated in dorsal-dependent regions and by alteration of the ventilation/perfusion ratio. The efficacy of this interventions can be demonstrated among other parameters by the course of the oxygenation index. The aim of our study is to analyze the prognostic value of the course of the oxygenation index before and after such an intervention.

Zygomycosis caused by Rhizopus species (Rhsp) is an aggressive and rapidly progressive opportunistic fungal infection in immunocompromised patients. It comprises mucocutaneous, rhinocerebral, pulmonary, urological and disseminated infections. Predisposing factors are immunosuppression owing to severe diseases, immune defects or metabolic disturbances like diabetic ketoacidosis. Rhizopus infections are characterized by angioinvasive growth, necroses of infected tissue and perineural invasion. The invasion of blood vessels is remarkable for a fungal infection. The mortality of zygomycosis is very high, especially for disseminated disease and if immunosuppression cannot be corrected.

In acute respiratory failure (ARF), in particular acute lung injury (ALI) and respiratory distress syndrome (ARDS), change from the supine position (SP) to the prone position (PP) or the use of kinetic therapy can improve oxygenation by recruiting alveoli situated in dorsal-dependent regions of the lung and by alteration of the ventilation/perfusion ratio. The efficacy of this intervention can be demonstrated by the course of oxygenation index. The aim of our study is to compare prone position ventilation (PP) and kinetic therapy (KT) in the first 5 days after intervention in patients with acute respiratory failure.

In acute respiratory failure (ARF), in particular acute lung injury (ALI) and acute respiratory distress syndrome (ARDS), change from the supine position (SP) to the prone position (PP) can improve oxygenation by recruiting alveoli situated in dorsal-dependent regions and by alteration of the ventilation/perfusion ratio. The efficacy of this intervention is shown by the course of oxygenation index. The aim of our study is to demonstrate different effects of prone position ventilation (PPV) in ARF in patients with different concomitant diseases.

In acute respiratory failure, classified as acute lung injury (ALI) or the more severe acute respiratory distress syndrome (ARDS), prone position ventilation (PPV) can improve oxygenation by recruiting alveoli situated in dorsal-dependent regions of the lung and by alteration of the ventilation/perfusion ratio. The aim of our study is to analyze the prognostic value of the change of oxygenation after starting prone position ventilation in ARF.

In acute respiratory failure (ARF), in particular acute lung injury (ALI) and respiratory distress syndrome (ARDS), change from supine (SP) to prone position (PP) can improve oxygenation. The efficacy of this intervention can be demonstrated by the course of oxygenation index. Nevertheless prone position ventilation (PPV) showed no improvement in survival so far. Endpoint for the assessment of therapeutic effects of an intervention like PPV is generally the mortality rate. The aim of our study is to attempt to analyze the discrepancy between positive effects of prone position ventilation on oxygenation index in ARF and the comparatively high mortality rates despite of this intervention. We studied 110 consecutive patients with ALI (n = 18) and ARDS (n = 92) at mean age 66 ± 13 [SE] years in a clinical follow-up design at a surgical ICU in a university hospital, who met the criteria of the American European consensus definition. All patients were ventilated intermittent in SP and in PP (135° left/right-side-position) for at least 6 hours/day. Data collection included apart from baseline characteristics individual oxygenation index and underlying diseases of the patients, in particular if of benign or malignant nature. We compared individual oxygenation index (PaO2/FiO2) before and after start of prone position (SPSS® T-test) and the data set of each patient with outcome. PPV was well tolerated in all n = 110 patients and showed an significant increase of PaO2/FiO2 in n = 106 within the first 6 hours (SP 149 ± 0.52 vs PP 230 ± 0.73 mmHg [mean ± SEM]). In the remaining four cases there was a positive effect within the first 24 hours. Sixty-seven (61%) of the patients died in the course of intensive care therapy and 43(39%) survived. Seven died with an oxygenation index below 100, another 36 with a ratio below 200, 17 below 300 and seven above 300 mmHg. Patients with a malignant underlying disease as cofactor had a 1.8 times higher and those with sepsis a 3.15 times higher risk to die during their ICU-stay despite of PPV. Despite of positive effects of PPV on oxygenation in our patients a considerable part of them died. To our amazement oxygenation index previous to death was not the main problem for most part of the patients in that phase. Malignant diseases in history and sepsis during the ICU-stay seem to increase the risk to die in the course of ALI or ARDS regardless the use of PPV conspicuously. Our results show that for the assessment of a therapeutic intervention in acute respiratory failure not only mortality as an endpoint seems to be suitable, but also important clinical cofactors.

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

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

Severe metabolic alkalosis is a common problem in ICU due to high gastric reflux, diuretic drugs or parenteral nutrition. The mortality is considerable. Therapy of severe metabolic alkalosis with hydrochloric acid is widely accepted and described as save and effective.

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

Bleeding into the tracheobronchial tree is a potentially fatal occurrence for intubated patients. The subsequent acute respiratory failure requires an effective therapy. Fiberoptic bronchoscopy represents an easy available technique for the diagnosis and treatment of this type of hemoptysis.

Procalcitonin (PCT) has recently attracted attention as a possible marker of the systemic inflammatory response to infection. Downregulation of PCT in healthy human subjects after repetitive injection of endotoxin has been published. This effect was not investigated in critical ill patients so far.