Search

Avoiding in-hospital transmissions has been crucial in the COVID-19 pandemic. Little is known on the extent to which hospital-acquired SARS-CoV-2 variants have caused infections in Germany.To analyse the occurrence and the outcomes of HAI with regard to different SARS-CoV-2 variants.Patients with SARS-CoV-2 infections hospitalized between March 1In all, 62,875 SARS-CoV-2 patients were analysed, of whom 10.6% had HAI. HAIs represented 14.7% of SARS-CoV-2 inpatients during the Wildtype period, 3.5% during Alpha (odds ratio: 0.21; 95% confidence interval: 0.19-0.24), 8.8% during Delta (2.70; 2.35-3.09) and 10.1% during Omicron (1.10; 1.03-1.19). When age and comorbidities were accounted for, HAI had lower odds for death than community-acquired infections (0.802; 0.740-0.866). Compared to the Wildtype period, HAIs during Omicron were associated with lower odds for ICU (0.78; 0.69-0.88), ventilation (0.47; 0.39-0.56), and death (0.33; 0.28-0.40).Hospital-acquired SARS-CoV-2 infections occurred throughout the pandemic, affecting highly vulnerable patients. Although transmissibility increased with newer variants, the proportion of HAIs decreased, indicating improved infection prevention and/or the effect of immunization. Furthermore, the Omicron period was associated with improved outcomes. However, the burden of hospital-acquired SARS-CoV-2 infections remains high.

Background Syndromic surveillance of severe acute respiratory infections (SARI) is important to assess seriousness of disease as recommended by WHO for influenza. In 2015 the Robert Koch Institute (RKI) started to collaborate with a private hospital network to develop a SARI surveillance system using case-based data on ICD-10 codes. This first-time description of the system shows its application to the analysis of five influenza seasons. Methods Since week 40/2015, weekly updated anonymized data on discharged patients overall and on patients with respiratory illness including ICD-10 codes of primary and secondary diagnoses are transferred from the network data center to RKI. Retrospective datasets were also provided. Our descriptive analysis is based on data of 47 sentinel hospitals collected between weeks 1/2012 to 20/2016. We applied three different SARI case definitions (CD) based on ICD-10 codes for discharge diagnoses of respiratory tract infections (J09 - J22): basic CD (BCD), using only primary diagnoses; sensitive CD (SCD), using primary and secondary diagnoses; timely CD (TCD), using only primary diagnoses of patients hospitalized up to one week. We compared the CD with regard to severity, age distribution and timeliness and with results from the national primary care sentinel system. Results The 47 sentinel hospitals covered 3.6% of patients discharged from all German hospitals in 2013. The SCD comprised 2.2 times patients as the BCD, and 3.6 times as many as the TCD. Time course of SARI cases corresponded well to results from primary care surveillance and influenza virus circulation. The patients fulfilling the TCD had been completely reported after 3 weeks, which was fastest among the CD. The proportion of SARI cases among patients was highest in the youngest age group of below 5-year-olds. However, the age group 60 years and above contributed most SARI cases. This was irrespective of the CD used. Conclusions In general, available data and the implemented reporting system are appropriate to provide timely and reliable information on SARI in inpatients in Germany. Our ICD-10-based approach proved to be useful for fulfilling requirements for SARI surveillance. The exploratory approach gave valuable insights in data structure and emphasized the advantages of different CD.

Objective Lowering of mortality rates in hospitals with mortality rates higher than accepted reference values for acute myocardial infarction (AMI), congestive heart failure (CHF), pneumonia, stroke, mechanical ventilation (MV) and colorectal surgery by using an external peer review process that identifies areas requiring rectification and implements protocols directed at improving these areas. Design Retrospective, observational, quality management study using administrative data to compare in-hospital mortality rates (pre and post an external peer review process that included adoption of improvement protocols) with reference values. Setting German general hospitals of a large, private group. Participants Hospitals with mortality rates higher than reference values. Interventions Peer review of medical records by experienced, outside physicians triggered by in-hospital mortality rates higher than expected. Inadequacies were identified, improvement protocols enforced and mortality rates subsequently re-examined. Main outcome measures Mortality rates 1 year before and 1 year after peer review and protocol use. Results For AMI, CHF, pneumonia, stroke, MV and colorectal surgery, the mortality rates 1 year post-peer review were significantly decreased as compared to pre-peer review mortality rates. The standardized mortality ratio for all of the above diagnoses was 1.45, 1 year before peer review, and 0.97, 1 year after peer review. The absolute risk reduction of 7.3% translates into 710 deaths in this population which could have been prevented. Conclusions Peer review triggered and conducted in the manner described here is associated with a significant lowering of in-hospital mortality rates in hospitals that previously had higher than expected mortality rates.

To define a set of indicators that could be used to improve quality in intensive care medicine.An European Society of Intensive Care Medicine Task Force on Quality and Safety identified all commonly used key quality indicators. This international Task Force consisted of 18 experts, all with a self-proclaimed interest in the area. Through a modified Delphi process seeking greater than 90% consensual agreement from this nominal group, the indicators were then refined through a series of iterative processes.A total of 111 indicators of quality were initially found, and these were consolidated into 102 separate items. After five discrete rounds of debate, these indicators were reduced to a subset of nine that all had greater than 90% agreement from the nominal group. These indicators can be used to describe the structures (3), processes (2) and outcomes (4) of intensive care. Across this international group, it was much more difficult to obtain consensual agreement on the indicators describing processes of care than on the structures and outcomes.This document contains nine indicators, all of which have a high level of consensual agreement from an international Task Force, which could be used to improve quality in routine intensive care practice.

BACKGROUND The abdominal compartment syndrome (ACS) is a life-threatening condition and may affect any critically ill patient. Little is known about the recognition and management of the ACS in Germany. METHODS A postal questionnaire was sent to departments of surgery and anesthesia of German hospitals with more than 450 beds. RESULTS From the 222 eligible hospitals a total of 113 replies were received. Most respondents (95%) indicated that the ACS plays a role in their clinical practice. Measurement of intra-abdominal pressure (IAP) is not performed by 26% while it is routinely done by 30%. Intra-abdominal pressure is mostly (94%) assessed via the bladder pressure. Of the respondents 41% measure IAP only in those patients thought likely to develop ACS. Risk factors of the ACS would lead to IAP monitoring in 10-23% of cases. The majority (86%) would require signs of organ dysfunction together with exceeding the IAD threshold in order to opt for a surgical decompression. The attitude towards the critical threshold (>20 mmHg or >25 mmhg) divided respondents into two groups of similar size (39% compared to 47%, respectively). CONCLUSIONS German anesthesiologists and surgeons are familiar with the ACS. However, about one-quarter never measure IAP and there is a considerable variance as to which patients are at risk to develop ACS and how often IAP should be measured in these patients. This could indicate a lack of acceptance or simply a persisting need for more data concerning the avoidance and treatment of the ACS.

Background Scientific evidence is accumulating that non-invasive ventilation (NIV) may be beneficial for different patient groups with acute respiratory insufficiency (ARI). The aim of the new S3 guidelines is to propagate evidence-based knowledge about the indications and limitations of NIV in clinical practice. Methods A total of 28 experts from 12 German medical societies were involved in the process of development of the present guidelines. These experts systematically analyzed approximately 2,900 publications. Finally, the recommendations were discussed and approved in two consensus conferences. Results In hypercapnic ARI, NIV reduces the length of stay and mortality during intensive care treatment [grade A recommendation (A)]. Patients with cardiopulmonary edema should be treated with continuous positive airway pressure (CPAP) or NIV (A). For immunocompromized patients with ARI, NIV reduces the mortality (A). In patients with postextubation respiratory failure and during weaning from mechanical ventilation, NIV reduces the risk of reintubation (A). For patients who decline to be ventilated invasively, NIV may be an acceptable alternative (B). Non-invasive ventilation can also successfully be used in pediatric patients with ARI caused by different reasons (C). In acute respiratory distress syndrome (ARDS) NIV cannot generally be recommended because the failure rate is relatively high. Conclusion Non-invasive ventilation is still not as widely implemented in clinical medicine as would be expected on the basis of the scientific literature. The aim of the present guidelines is to further propagate NIV for the treatment of ARI.

Acute lung injury (ALI) is of paramount importance for modern intensive care since it is one of the most frequent conditions necessitating admission to an ICU. ALI is characterised by severe life threatening hypoxemia which is based on ventilation perfusion mismatching within the lung. This is mostly resulting from atelectasis formation due to primary or secondary inflammation of lung tissue. Many studies showed that this inflammatory process is not restricted to the respiratory system but might result in non pulmonary organ failure and hemodynamic compromise as well. Mechanical ventilation is considered the hallmark treatment for ALI patients aimed to recruit lung tissue and thereby reverse hypoxemia without causing additional lung injury potentially resulting from overdistention or cycling collapse during expiration. Scientific evidence shows us that prevention of ventilator induced lung injury by protective ventilation with reduced tidal volumes is resulting in better clinical outcomes. Moreover, different technologies and adjunctive therapies have been suggested based on their pathophysiology. All these treatment options will be summarized in this article. Given the clear evidence for protective ventilation and bearing in mind that clinical application of this easy concept is still not widespread we will focus on this aspect.

A pathological increase of intraabdominal pressure (IAP) is frequently observed in severely ill patients suffering from surgical diseases. This may lead to the abdominal compartment syndrome (ACS) which is characterized by an IAP >20 mmHg (>2.67 kPa) and failure of one or more organ systems. The mortality of ACS exceeds 60%. Knowledge concerning the sequelae of ACS is abundant, however, measurement of IAP is not routinely performed even if patients present with corresponding risk factors. This is probably due to a variable incidence of ACS and scepticism regarding the results of bladder pressure measurement. However, measurement of IAP can now be performed semi-automatically, continuously and in a standardized fashion. The therapy of ACS, i.e. decompression laparotomy and laparostomy, is undisputed. Since a heterogeneous group of patients can be affected, monitoring of IAP is indicated in patients needing intensive care. A consistent registration of IAP will improve knowledge and guidelines regarding the therapy of a pathologically increased IAP. Nevertheless, patients in whom ACS is suspected should be decompressed as soon as possible.

Sedation and analgesia are relevant aspects for the adequate treatment of patients in an intensive care unit. Recent drug developments and new strategies for ventilation provide improved sedation management allowing better adaptation to the clinical background and individual needs of the patient. This article provides an overview on the application of different substance groups. Focus is placed on newly developed pharmaceuticals such as dexmedetomidine. Another aspect is scoring system-related and EEG-based monitoring of depth of sedation. Modern concepts of analgesia and sedation for ICU patients have been developed based on the interaction of different parameters such as adaptive sedation and analgesia management (ASAM).

General anesthesia using volatile anesthetics leads to an almost complete inhibition of gastrointestinal motility which is rapidly reversible after removal of the anesthetic agent. When epidural or spinal anesthesia is used either for anesthesia or postoperative analgesia, gastrointestinal function is only slightly affected. In contrast to these rather clear effects of anesthetics, it is almost impossible to describe the impact of different analgosedation regimens on gastrointestinal function since no larger-scale clinical studies provide reliable data. It is clear that opioids and clonidine inhibit gastrointestinal motility through specific receptor sites. Benzodiazepines and propofol however, exert a general inhibiting effect due to their central effects, but they do not have any specific binding sites. No negative effects on gastrointestinal motility have been found for ketamine. Since all modern strategies for analgosedation do prefer combinations of different substances, one should be aware that these combinations effect the gastrointestinal function in the clinical setting.

Mechanical ventilation is a lifesaving procedure in routine intensive care medicine. However, during recent years we have learned that intubation and prolonged mechanical ventilation can be associated with quite serious side effects. Therefore, one of the major goals in the management of the mechanically ventilated patient is to liberate the patient from the ventilator at the earliest time possible. In about 20% of all mechanically ventilated patients, the process of weaning is difficult and time consuming so that these patients need a specific weaning technique. It has been shown that the duration of weaning might be shortened and its outcome might be improved when standardized protocols are used to detect the earliest time when a patient is able to breath spontaneously. However, although this evidence suggests that it is in general possible to improve the process of weaning, those studies have not resulted in a clear preference for one or the other weaning method. Both, T-piece trials as well as spontaneous breathing trials with low level pressure support have been successfully used for weaning. Since it is well known that the intubated patients has to overcome an additional breathing workload which is imposed mainly by the endotracheal tube, we have a preference for the spontaneous breathing trials using pressure support to compensate for this added workload.

Objective: To evaluate the effect of inhaled nitric oxide (NO) on gas exchange and haemodynamics during partial liquid ventilation, in a saline lung lavage model of acute lung injury (ALI) in pigs. Design: Prospective, controlled study. Setting: Animal research facilities of a university hospital. Subjects: Twelve medium-sized pigs. Interventions: After induction of ALI in 12 pigs (25±5 kg body weight), partial liquid ventilation was initiated with 30 ml kg-1 perfluorocarbon (FC 3280 ®). Subsequently, 0.1 ppm, 1 ppm, 10 ppm and 100 ppm NO were sequentially added to the inspiratory gas, interrupted by time periods without NO inhalation. Measurements and main results: PaO2, PaCO2 and venous admixture did not reveal any significant change following partial liquid ventilation or the additional inhalation of NO. However, a large variety of individual responses were observed in the studied group of animals. Mean pulmonary pressure increased significantly after inhalation of 10 ppm NO and 100 ppm NO was interrup...

Background: Two prototypes for integrated nitric oxide (NO) administration during mechanical ventilation have recently been developed (Servo 300 NO-A prototype, Siemens, Lund, Sweden; NO-domo, Drager AG, Lubeck, Germany). Objectives: To test the accuracy for the administration and the inbuilt electrochemical NO/NO2 measurement of these prototypes. Design: Different NO concentrations (NOin, 0.5-90 ppm) and different tidal volumes (TV, 100-250 ml for paediatric patients, 300-1,000 ml for adult patients) were tested. Both the adjusted NOin as well as the electrochemical measurement were compared to chemiluminescence as the reference method. Results: The mean difference between NOin and chemiluminescence measurements was 0.46±0.72 ppm for the Servo and 0.61±2.01 ppm for the NO-domo. This difference was dependent on TV and NOin. For NOin ≤40 ppm and the adult range of TV, the mean difference was 0.17±0.25 ppm for the Servo and 1.00±0.48 ppm for the NO-domo. The comparison between the electrochemical measureme...

The airway occlusion pressure, P0.1, is the negative airway pressure generated during the first 100 msec of an occluded inspiration. P0.1 is a parameter for the neuro-muscular activation of the respiratory system, which is an important determinant for the work of breathing. It has been shown to be a good predictor for successful weaning from mechanical ventilation. Standard P0.1 measurement techniques are based on a total occlusion of the inspiration for more than 100 msec. These measurements are technically complex and therefore not useful for clinical purposes. Furthermore, a significant breath-by-breath variability has been shown for P0.1, which is neglected by any single point measurement technique. Therefore, we have developed a continuous on-line measurement for breath-by-breath determination of P0.1 using the Siemens Servo 900C respirator. In triggered mechanical ventilation the delay time between the onset of the patients inspiration and flow delivery from the respirator is more than 100 msec for this respirator. During that time the inspiration is occluded. Therefore, the trigger effort was proposed to be a good estimate of P0.1. Based on this, we calculated P0.1 as followsc airway pressure (Paw) was registered at the endotracheal tube site of the respiratory tubing, digitized and acquired by a personal computer at 100 Hz. The recorder output of the Servo 900C was connected to the same computer, delivering the electronical signal for the inspiratory valve to open when the inspiratory effort has exceeded the trigger threshold, which needs a minimal delay time of 80 msec. Around 20 msec after this signal flow is delivered from the respirator. The computer runs an algorithm, which recognizes this signal and calculates P0.1 (Servo P0.1) as the slope of the pressure drop during this 100 msec. Paw tracings and the calculated P0.1 values were displayed on the computer screen and stored on disk. This method was validated by comparing it to the standard technique, using a Hans-Rudolph valve for inspiratory occlusion and calculating P0.1 from Paw tracings during the occluded inspiration. For validation we used a mechanical lung model which generated P0.1 values ranging between 1.1-10.3 mbar. For a given adjustment of the lung model two standard measurements (standard P0.1) were made and compared to the Servo P0.1. In a total of 21 measurements the mean Servo P0.1 was 4.9\pm 2.9 mbar; the mean standard P0.1 was 4.3\pm 2.5 mbar. The mean difference between Servo P0.1 and standard P0.1 was 0.6\pm 0.6 mbar (range: -0.3-1.8 mbar). The regression equation for linear regression analysis was: Servo {\rm P}0.1 = 1.15 * {\rm standard\ P}0.1-0.05. This correlation was significant (r=0.99, p

Our objective was to determine the effects of vasodilatory treatment with epoprostenol (PGI2) and nitroglycerin (NTG) on systemic oxygen delivery index (DO2) and hepatic venous oxygen saturation (SvhO2) after liver transplantation. This prospective study used repeated-measures design. Fifteen adult patients undergoing orthotopic liver transplantation (OLT) were enrolled. Postoperatively, a fiberoptic pulmonary artery catheter was inserted into the right hepatic vein and a timed infusion of PGI2 and NTG was sequentially performed in random order at the following rates: PGI2 at 5 ng/kg/minute and NTG at 0.1 microgram/kg/minute. Each step in each sequence lasted 45 minutes, followed by a control interval of 45 minutes. Measurements were taken at the end of each period when hemodynamic function was stable. Systemic hemodynamics, DO2, oxygen uptake index (VO2), mixed venous oxygen saturation (SvO2), and SvhO2 were assessed. We found that PGI2 induced an increase of cardiac index (+18%, p < .05); DO2 (+16%, p < .05); and SvhO2 (+11%, p < .05). Mean arterial pressure was decreased during PGI2 infusion (-9%, p < .05), as well as during infusion of NTG (-10%, p < .05). NTG significantly decreased DO2 (-6%, p < .05) and SvhO2 (-4%, p < .05). Neither drug affected VO2. We conclude that PGI2 induced vasodilation and increased systemic oxygen delivery in parallel with SvhO2, suggesting a corresponding increase of hepatic oxygen supply. NTG induced systemic vasodilation and significantly impaired hepatic venous oxygen saturation and DO2. Thus, if vasodilatory therapy is indicated in the patient after liver transplantation, PGI2 appears to be better than NTG in improving DO2 without impairing splanchnic oxygenation.

The airway occlusion pressure, P0.1, is an index for the neuro-muscular activation of the respiratory system. It has been shown to be a very useful indicator for the ability of patients receiving ventilatory support to be weaned from mechanical ventilation. Since the standard measurement technique for P0.1 determination is technically complex, it is not widely available for clinical purposes. For that reason a P0.1 measurement technique was developed as an integrated function in a standard respirator (Evita, Drager, Lubeck, Germany). This technique is easy to use and does not need any further equipment. We validated this new technique by comparing it to standard P0.1 measurements in a mechanical lung model as well as in ventilated patients. In the lung model we found a correlation between the Evita measurement and standard measurements of r = 0.99. In 6 ventilated patients the correlation was r = 0.78. Since the Evita P0.1 and the standard measurement had to be performed during two different breaths, this little poorer correlation in patients may be due to a significant breath-by-breath variability in P0.1. Comparing the Evita P0.1 and the standard measurement within one breath resulted in a clearly better correlation (r = 0.89). We conclude that this new measurement technique provides an easy and accurate P0.1 measurement using standard respiratory equipment when tested in a lung model. In patient measurements the method is less precise, which is probably due to the variable waveforms of the inspiratory driving pressure seen in patients, for example when intrinsic PEEP is present.(ABSTRACT TRUNCATED AT 250 WORDS)

A prospective multicenter study was carried out from October 1 to November 30, 1991, to determine the incidence, severity, and mortality of acute respiratory failure (ARF) in Berlin, Germany, a metropolis with a population of 3.44 million. Adult patients from 72 intensive care units (ICUs) were evaluated. ARF was defined as: (1) intubation and mechanical ventilation (I+MV) > or = 24 h; age > or = 14 yr. Incidence of ARF was assessed as the number of patients fulfilling ARF criteria within the 2-mo study period. Severity of ARF was defined as "no lung injury" (NLI), "mild-to-moderate lung injury" (MMLI), and "severe lung injury" (SLI) according to Murray and coworkers' proposals. Mortality was assessed as number of patients with ARF dying during ICU stay. During the study period, 508 patients were diagnosed as having ARF, representing an incidence of ARF of 88.6 per 100,000/yr. Twenty-four h after I+MV, MMLI occurred in 94% and SLI in 3.6% of the ARF patients. Overall mortality rate was 42.7%. Mortality rate in the NLI group was 36.4%; in patients with MMLI, 40.8%; and in patients with SLI, 58.8%. Our data offer novel information on incidence, severity, and mortality of ARF in a major urban population.

In-hospital mortality of myocardial infarction, heart failure and pneumonia within a private hospital chain were compared with the German average since 2000.Increased in-hospital mortalities based on diagnosis coding with ICD-10 benchmarked with German average values induced peer reviews in concern hospitals. From 2000 until 2010, peer reviews as performed by at least 2 peers compared retrospectively case management and treatment with best care, classified the treatment and discussed it with responsible physicians. The classification consisted of category 1 for improvement potential, category 2 for miscoding and category 3 for sufficient treatment. Based on the improvement potential an operational plan of treatment improvement for the single hospital was produced which was to be realized by this hospital and supported by concern activities for knowledge improvement.In 2000, the indicators in-hospital mortality of myocardial infarction, heart failure and pneumonia of the hospital chain exceeded German average whereas in 2008 these values were lower (i. e. better) than German average. The peer reviews detected large improvement potentials in treatment processes and helped to improve them.Peer reviews as triggered by quality indicators supported improvement of treatment and likely outcomes.

Spontaneous ventilation is a popular mode of ventilation for patients with the laryngeal mask airway (LMA). Studies have shown, however, that spontaneous ventilation impairs gas exchange and that assisting or controlling ventilation results in higher oxygen saturation. Atelectasis during general anesthesia is a well described mechanism which impacts on gas exchange. Positive end-expiratory pressure (PEEP) increases the lung volume available for gas exchange. This study investigated whether the application of PEEP leads to an improvement of oxygen saturation in unassisted spontaneously breathing patients with a LMA. A total of 80 adult patients under general anesthesia were prospectively randomized into two groups. Both groups were left to breathe spontaneously. In group 1 the adjustable pressure limiting (APL) valve was opened resulting in zero end-expiratory pressure. In group 2 the valve was set to a PEEP of +7 cm H₂O. Oxygen saturation was measured by pulse oxymetry at four different phases: pre-induction, after induction and insertion of the LMA, during maintenance and in recovery. The application of PEEP did not improve oxygen saturation. In both groups the mean oxygen saturation was similar (97.2±1.8% in group 1 versus 97.2±1.9% in group 2, p=0.941) during maintenance. No effect on oxygen saturation in recovery could be found either (96.0±1.8% in group 1 versus 96.1±2.0% in group 2, p=0.952) and hemodynamics were unaffected by the application of PEEP. The application of a PEEP of +7 cm H₂O with a LMA under spontaneous ventilation cannot be recommended. Limitations of our study were the selection of healthy patients and omitting pre-oxygenation before induction which might have limited the development of atelectasis. In addition arterial partial pressure of oxygen (p(a)O₂) measurements could have revealed subtle changes in oxygenation.

This study in conscious, chronically instrumented dogs investigated the effects of human atrial natriuretic peptide [hANP-(99-126)] at physiological (5 ng.kg-1.min-1) and pharmacological (5-900 ng.kg-1.min-1) doses on angiotensin II (ANG II)-mediated effects on hemodynamics, renal excretion, and aldosterone release. Five female beagle dogs kept chronically on a dietary sodium intake of 2.5 mmol Na.kg body wt-1.day-1 received an intravenous infusion of 1, 4, 10, 20, and 50 ng.kg-1.min-1 ANG II (20-min periods) without (protocol 1) or with (protocol 2) simultaneous intravenous infusion of 5 ng.kg-1.min-1 hANP-(99-126). In protocol 1, glomerular filtration rate (means +/- SD) decreased from 4.0 +/- 0.6 to 2.8 +/- 0.5 ml.kg-1.min-1, renal sodium excretion (UNaV) decreased from 2.8 +/- 1.6 to 0.4 +/- 0.2 mumol.kg-1.min-1, and urine volume (V) decreased from 45 +/- 23 to 6 +/- 8 microliters.kg-1.min-1. There were no differences in the values between protocol 1 and protocol 2. Mean arterial blood pressure (MABP) increased similarly from 118 +/- 16 to 166 +/- 9 mmHg in protocol 1 and from 109 +/- 11 to 162 +/- 7 mmHg in protocol 2. Maximal aldosterone secretion was stimulated less in protocol 2 (481 +/- 92 vs. 362 +/- 158 pg/ml; P less than 0.05). In ANG II-pretreated (20 ng.kg-1.min-1) dogs (n = 4; protocol 3), intravenous hANP-(99-126) doses of 300-900 ng.kg-1.min-1 decreased MABP and central venous pressure.(ABSTRACT TRUNCATED AT 250 WORDS)

The abdominal compartment syndrome (ACS) is a life-threatening condition and may affect any critically ill patient. Little is known about the recognition and management of the ACS in Germany.A postal questionnaire was sent to departments of surgery and anesthesia of German hospitals with more than 450 beds.From the 222 eligible hospitals a total of 113 replies were received. Most respondents (95%) indicated that the ACS plays a role in their clinical practice. Measurement of intra-abdominal pressure (IAP) is not performed by 26% while it is routinely done by 30%. Intra-abdominal pressure is mostly (94%) assessed via the bladder pressure. Of the respondents 41% measure IAP only in those patients thought likely to develop ACS. Risk factors of the ACS would lead to IAP monitoring in 10-23% of cases. The majority (86%) would require signs of organ dysfunction together with exceeding the IAD threshold in order to opt for a surgical decompression. The attitude towards the critical threshold (20 mmHg or25 mmhg) divided respondents into two groups of similar size (39% compared to 47%, respectively).German anesthesiologists and surgeons are familiar with the ACS. However, about one-quarter never measure IAP and there is a considerable variance as to which patients are at risk to develop ACS and how often IAP should be measured in these patients. This could indicate a lack of acceptance or simply a persisting need for more data concerning the avoidance and treatment of the ACS.

Scientific evidence is accumulating that non-invasive ventilation (NIV) may be beneficial for different patient groups with acute respiratory insufficiency (ARI). The aim of the new S3 guidelines is to propagate evidence-based knowledge about the indications and limitations of NIV in clinical practice.A total of 28 experts from 12 German medical societies were involved in the process of development of the present guidelines. These experts systematically analyzed approximately 2,900 publications. Finally, the recommendations were discussed and approved in two consensus conferences.In hypercapnic ARI, NIV reduces the length of stay and mortality during intensive care treatment [grade A recommendation (A)]. Patients with cardiopulmonary edema should be treated with continuous positive airway pressure (CPAP) or NIV (A). For immunocompromized patients with ARI, NIV reduces the mortality (A). In patients with postextubation respiratory failure and during weaning from mechanical ventilation, NIV reduces the risk of reintubation (A). For patients who decline to be ventilated invasively, NIV may be an acceptable alternative (B). Non-invasive ventilation can also successfully be used in pediatric patients with ARI caused by different reasons (C). In acute respiratory distress syndrome (ARDS) NIV cannot generally be recommended because the failure rate is relatively high.Non-invasive ventilation is still not as widely implemented in clinical medicine as would be expected on the basis of the scientific literature. The aim of the present guidelines is to further propagate NIV for the treatment of ARI.

Acute lung injury (ALI) is of paramount importance for modern intensive care since it is one of the most frequent conditions necessitating admission to an ICU. ALI is characterised by severe life threatening hypoxemia which is based on ventilation perfusion mismatching within the lung. This is mostly resulting from atelectasis formation due to primary or secondary inflammation of lung tissue. Many studies showed that this inflammatory process is not restricted to the respiratory system but might result in non pulmonary organ failure and hemodynamic compromise as well. Mechanical ventilation is considered the hallmark treatment for ALI patients aimed to recruit lung tissue and thereby reverse hypoxemia without causing additional lung injury potentially resulting from overdistention or cycling collapse during expiration. Scientific evidence shows us that prevention of ventilator induced lung injury by protective ventilation with reduced tidal volumes is resulting in better clinical outcomes. Moreover, different technologies and adjunctive therapies have been suggested based on their pathophysiology. All these treatment options will be summarized in this article. Given the clear evidence for protective ventilation and bearing in mind that clinical application of this easy concept is still not widespread we will focus on this aspect.

Since October 2003 new regulations for qualifications to practice medicine in Germany now require compulsory courses in anaesthesiology. Therefore, existing curricular activities had to be changed from facultative courses for a small number of interested students to compulsory activities for all students.Previous data of the department of anaesthesiology at the University Hospital Aachen (Germany) were collected and taken into consideration for the development of a new curriculum: The result was a course consisting of a tutorial with integrated "basic skill training", practical training in the operating theatre and a simulation-based session, in addition to two series of lectures. An evaluation by the students was carried out using EvaLuna as a tool for web-based on-line evaluation and faculty members had to fill out a standardized questionnaire.The different parts of the curriculum received the highest scores of all courses in the undergraduate medical school curriculum. Best results were achieved by the anaesthesia-simulation session followed by the tutorial and the practical training.The feedback of faculty members as well as the results of students' evaluation approved the developed concept of integrating anaesthesia-relevant issues into the formal medical school curriculum. Nevertheless, the on-line evaluation system EvaLuna provided additional suggestions for future improvements in the newly created curriculum.