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ZusammenfassungKritisch kranke Patienten können aufgrund unterschiedlicher Krankheitsbilder eine akute hämodynamische Instabilität entwickeln. Die Diagnostik und Therapie ist insbesondere dann erschwert, wenn die eigentliche Ursache der Kreislaufinstabilität von Begleiterkrankungen maskiert wird. Wir berichten über einen Patienten, der auf der Schwerverbrannten-Intensivstation wenige Tage nach einem schweren Stromunfall eine akute Kreislaufinstabilität zunächst unklarer Genese entwickelte.

Introduction Given the lack of reliable evidence on the utility of continuous lateral rotational therapy (CLRT) in chest trauma, we performed a single-centre retrospective matched-pair analysis of patients treated either with CLRT or non-continuous manual turning after blunt thoracic trauma. Methods We included adult patients that were admitted to our level 1 trauma centre from 2010-2014 and presented with severe thoracic injuries (AISThorax ≥3) within 24 h after the injury and required at least 72 h of mechanical ventilation. Patients were either treated with manual turning every 2–4 h or CLRT. To ensure comparable injury severity and a similar risk for posttraumatic respiratory complications, we matched for thoracic injury severity, age, additional injuries (head, abdomen, extremities) and need for massive transfusion. Results A total of 22 pairs (n = 44 patients) were successfully matched and analysed. The use of CLRT did not have a statistically significant impact on respiratory function, gas exchange, duration of mechanical ventilation, ICU or hospital length of stay, or overall patient outcomes (e.g. pneumonia, sepsis, ARDS, mortality). During active rotation the level of sedation was lower compared to manual turning (Richmond Agitation Sedation Scale; manual turning: −3.6; CLRT: −4.0; p = 0.01). Patient agitation was noticed more frequently in the CLRT group (manual turning: n = 2 (9%); CLRT: n = 9 (41%); p = 0.02). Discussion In this well-matched sample, the use of CLRT did not seem to translate into relevant clinical benefits in patients with thoracic trauma in the setting of modern ICU care with the widespread implementation of lung protective ventilation. However, statistical power and generalisability were limited by the small sample size and single centre design. A large RCT is required to provide conclusive results.

ZusammenfassungBei einer Sepsis sind eine adäquate Diagnostik und Therapie von wesentlicher prognostischer Bedeutung. Neben der Blutkulturanalyse werden u. a. Biomarker wie das Procalcitonin (PCT) in der Diagnostik und zur Steuerung der antibiotischen Therapie eingesetzt. Aktuelle Daten legen nahe, dass eine PCT-gesteuerte Therapie auch das Outcome verbessern kann. Das PCT als diagnostisches Instrument ist jedoch mit einigen Einschränkungen verbunden.

Antibiotika sicher, schnell und effizient verordnen Infektionen auf der Intensivstation sind unverändert von größter Bedeutung. Wie auch die EPIC III-Studie zeigt, sind erworbene Infektionen ein unabhängiger Faktor für eine erhöhte Sterblichkeit, was auch auf mit Resistenzen verbundene Problemerreger zutrifft. Daher stellen Infektionen auf der Intensivstation eine maximale Bedrohung für den Patienten und den Behandlungserfolg dar. Aktuelle Studien zeigen, dass die Behandlung mit Antibiotika bei lebensbedrohlich kranken Patienten sofort erfolgen muss. Häufig bedeuten schon wenige Stunden Zeitverzögerung für die Patienten ein deutlich erhöhtes Sterblichkeitsrisiko. Intensivmediziner müssen daher schnellstens eine adäquate anti-infektive Therapie einleiten und dürfen dabei auch die Therapiekosten nicht aus den Augen verlieren. Auch in der 4. überarbeiteten Auflage geben die erfahrenen Autoren aktuelle Entscheidungshilfen mit Fokussierung auf das konservative und operative intensivmedizinische Infektionsspektrum und einer indikationsorientierteren Gliederung. Aus dem Inhalt: • Substanzklassen und Wirkmechanismen • Typische chirurgisch-intensivmedizinische Infektionen • Therapieversager • Perioperative Antibiotikaprophylaxe • Antibiotikatherapie bei Niereninsuffizienz und Nierenersatztherapie • Antibiotikatherapie in der Schwangerschaft und Stillzeit • Antibiotikatherapie bei Kindern und Jugendlichen • Antibiotikatherapie bei Übergewichtigen • Therapiekosten Die richtige Entscheidung treffen!

Global end-diastolic volume (GEDV) as determined at the bedside by the transpulmonary technique is a reliable marker of cardiac preload in critically ill patients. As shown by numerous studies, GEDV is superior to cardiac filling pressures in various settings in anesthesia and intensive care medicine in patients undergoing mechanical ventilation. Furthermore, in scenarios such as open-chest conditions, GEDV should be particularly considered and used for these purposes as dynamic parameters are associated with limitations. Clinical data from patients undergoing elective cardiac and noncardiac surgery showed that goal-directed treatment using GEDV for preload assessment is associated with the potential to reduce vasoactive drugs, gain stable metabolic conditions, and shorten the length of stay on the intensive care unit. However, further and adequately designed prospective clinical trials are required to underline and differentiate the impact of GEDV-guided hemodynamic management on the outcome of critically ill patients.

Single transpulmonary thermodilution (SD) with extravascular lung water index (EVLWI) could become a new tool to better assess lung graft edema during ex-vivo lung perfusion (EVLP). In this study we compare EVLWI with conventional methods to better select lungs during EVLP and to predict post-transplant primary graft dysfunction (PGD).We measured EVLWI, arterial oxygen/fraction of inspired oxygen (P/F) ratio, and static lung compliance (SLC) during EVLP in an observational study. At the end of EVLP, grafts were accepted or rejected according to a standardized protocol blinded to EVLWI results. We compared the respective ability of EVLWI, P/F, and SLC to predict PGD. Mann-Whitney U-test, Fisher's exact test, and receiver-operating characteristic (ROC) curve data were used for analysis. p0.05 was considered statistically significant.Thirty-five lungs were evaluated by SD during EVLP. Three lungs were rejected for pulmonary edema. Thirty-two patients were transplanted, 8 patients developed Grade 2 or 3 PGD, and 24 patients developed Grade 0 or 1 PGD. In contrast to P/F ratio, SLC, and pulmonary artery pressure, EVLWI differed between these 2 populations (p0.001). The area under the ROC for EVLWI assessing Grade 2 or 3 PGD at the end of EVLP was 0.93. Donor lungs with EVLWI7.5 ml/kg were more likely associated with a higher incidence of Grade 2 or 3 PGD at Day 3.Increased EVLWI during EVLP was associated with PGD in recipients.

First aid and treatment of burn patients pose a challenge to responsible physicians. Primary assessment should include an evaluation of the degree and extent of the burn injuries as well as a physical examination for other trauma injuries and trauma caused by the inhalation of toxic agents. One should focus on removal of the burning source, preservation of body temperature, sterile coverage of the burnt areas, pain management and sufficient hemodynamic stabilization. Grade IIb and more severe burns are most likely subject to surgical intervention to assure sufficient healing. Our case report illustrates a burn patient's initial treatment and clinical course, which includes the development of an acute pulmonary embolism with severe hemodynamic instability. As other critically ill patients, burn patients are at particular risk for complications like infections or other causes for hemodynamic instability. Every cardiovascular event is possibly suspicious for acute pulmonary arterial embolism (PAE). A high or increasing gap between expiratory and arterial COKritisch kranke Patienten können aufgrund unterschiedlicher Krankheitsbilder eine akute hämodynamische Instabilität entwickeln. Die Diagnostik und Therapie ist insbesondere dann erschwert, wenn die eigentliche Ursache der Kreislaufinstabilität von Begleiterkrankungen maskiert wird. Wir berichten über einen Patienten, der auf der Schwerverbrannten-Intensivstation wenige Tage nach einem schweren Stromunfall eine akute Kreislaufinstabilität zunächst unklarer Genese entwickelte.

Background Because of their simplicity, uncalibrated pulse contour (UPC) methods have been introduced into clinical practice in critical care but are often validated with a femoral arterial waveform. Objective We aimed to test the accuracy of cardiac index (CI) measurements and trending ability from a radial artery with one UPC. Design An observational study. Setting Tertiary care mixed-surgical ICU. Data were obtained from April 2015 to July 2016. Patients We studied 20 critically ill mechanically ventilated patients monitored by UPC (PulsioFlex; Pulsion Medical Systems SE, Feldkirchen, Germany). We used transpulmonary thermodilution (PiCCO2) as a reference. Main outcome measures Bland-Altman-analyses with percentage errors were calculated to assess the accuracy of CI values from radial pulse contour analysis (CIRAD), autocalibration (CIAC) and femoral pulse contour analysis (CIFEM). All were compared with a reference (CITD) at 4-h intervals for 24 h. Trending ability was assessed by polar-plots and four-quadrant-plots. CI is given in l min m. Results Bland-Altman-analyses: for CIRAD, the mean bias was -0.1 with limits of agreement (LOA) of -2.9 to 2.7 and a percentage error of 70%; for CIAC, the mean bias was 0 with LOA -2.8 to 2.7 and a percentage error of 70%; for CIFEM, the mean bias was 0 with LOA -1.2 to 1.2 and a percentage error of 30%, respectively. Polar plots for trending: for CIRAD, the angular bias was 12° with radial LOA of 39°, a polar concordance rate of 73% and a concordance rate of 67% in the four-quadrant-plot; for CIAC, the angular bias was 4° with radial LOA of 41°, polar concordance rate of 79% and a concordance rate of 74% in the four quadrant plot; for CIFEM, the angular bias was -2° with radial LOA of 50°, polar concordance rate of 74% and a concordance rate of 81%. Conclusion In critically ill patients, the PulsioFlex system connected to a radial arterial catheter is inaccurate for CI measurements and does not track changes in CI adequately. We therefore recommend using validated thermodilution techniques for monitoring in the critical care setting.

Ausere Drainagen spielen in der Intensivmedizin eine grosere Rolle, sodass auf diese Art der Drainagen in diesem Kapitel besonders eingegangen werden soll. Die Funktion der auseren Drainagen liegt zum einen in der Ableitung und somit Volumenentlastung von Flussigkeit oder Gas, zum anderen ist gerade bei postoperativ angelegten Drainagen auch eine sog. „Wachterfunktion“ relevant. Hierunter versteht man, dass durch die Menge und das Aussehen des abgeleiteten Sekrets wichtige Hinweise gewonnen werden konnen. Beispielsweise kann so eine Nachblutung erkannt und quantifiziert werden. Des Weiteren kann das gewonnene Material aus der Drainage mikrobiologisch, laborchemisch und histopathologisch untersucht werden.

We read with great interest the excellent article by Della Torre et al. on the management of acute respiratory distress syndrome (ARDS) in patients with traumatic brain injury (TBI) (1). This thorough review, which deals extensively with the ventilatory management of patients with ARDS and TBI, may benefit from further expansion on the challenging hemodynamic management of these patients.

Adequate diagnosis and therapy of sepsis is of major prognostic relevance. Besides the gold standard (blood culture diagnostics) biomarkers, e.g. serum procalcitonin (PCT), are clinically increasingly used in the diagnosis and for guiding anti-infective treatment. Recent guidelines recommend early determination of PCT. However, trauma, burns, surgical procedure, and intoxications may significantly impact PCT levels. As a rare cause, PCT producing tumors have been described and may be potentially misleading in the clinical setting. While several other constellations for increased PCT in the absence of sepsis (e.g., trauma, intoxications) have been described, it needs to be summarized that according to currently available data, sensitivity and specificity for PCT for the diagnosis of sepsis in critically ill patients is on average between 70 and 80%. Thus, PCT must be interpreted carefully in the context of medical history, physical examination, and microbiological assessment. However, the existing body of literature emphasizes the value of PCT to shorten the duration of an antibiotic treatment. So far, different cut-off values for PCT for certain infections have been identified. While different treatment algorithms have been studied, PCT-guided treatment not only enables to reduce use of antibiotics but as shown most recently may improve outcome of critically ill patients.Bei einer Sepsis sind eine adäquate Diagnostik und Therapie von wesentlicher prognostischer Bedeutung. Neben der Blutkulturanalyse werden u. a. Biomarker wie das Procalcitonin (PCT) in der Diagnostik und zur Steuerung der antibiotischen Therapie eingesetzt. Aktuelle Daten legen nahe, dass eine PCT-gesteuerte Therapie auch das Outcome verbessern kann. Das PCT als diagnostisches Instrument ist jedoch mit einigen Einschränkungen verbunden.

Monitoring of cardiac index (CI) by uncalibrated pulse contour (PC) methods has been shown to be inaccurate in critically ill patients. We tested accuracy and trending of a new pulse contour method and a modified Fick method using central venous oxygen saturation. We studied 21 critically ill and mechanically ventilated patients (age 20–86 years) monitored by PC (PulsioFlex®) and transpulmonary thermodilution (TPTD, PiCCO2®) as reference. At baseline, reference and PC–derived CI (CIPC) were recorded and CI obtained by Fick's method (FM, CIFICK). After four hours, measurements were performed analogously for trending analysis. CI are given in l/min/m2as mean ± standard deviation. At baseline CITPTDwas 3.7 ± 0.7, CIPC3.8 ± 0.7 and CIFICK5.2 ± 1.8. After 4 hours, CITPTDwas 3.5 ± 0.6, CIPC3.8 ± 1.2 and CIFICK4.8 ± 1.7. Mean bias for PC at baseline was −0.1 (limits of agreement [LOA] −1.4 to 1.2) and −0.4 (LOA −2.6 to 1.9) after four hours. Percentage errors (PE) were 34% and 60% respectively. FM revealed a bias of −1.5 (LOA −4.8 to 1.8, PE 74%) at baseline and −1.5 (LOA −4.5 to 1.4, PE 68%) at four hours. With an exclusion window of 10% of mean cardiac index, trending analysis by polar plots showed an angular bias of 5° (radial LOA ± 57°) for PC and 16° (radial LOA ± 51°) for FM. Although PC values at baseline were marginally acceptable, both methods fail to yield clinically acceptable absolute values. Likewise, trending ability is not adequate for both methods to be used in critically ill patients.

Antibiotika sicher, schnell und effizient verordnen Patienten auf der Intensivstation sind in hohem Maße von Infektionen bedroht. Aktuelle Studien zeigen, dass die Behandlung mit Antibiotika bei lebensbedrohlich kranken Patienten sofort erfolgen muss. Häufig bedeuten schon wenige Stunden Zeitverzögerung für die Patienten ein erhöhtes Sterblichkeitsrisiko. Intensivmediziner müssen daher schnellstens eine adäquate antiinfektive Therapie einleiten, ohne dabei die Therapiekosten aus den Augen zu verlieren. Auch in der 3. überarbeiteten Auflage, ist es den Autoren gelungen, aktuelle Entscheidungshilfen für den intensivmedizinischen Klinikalltag zu geben. Aus dem Inhalt: - Neu: Aktuelle PEG-Leitlinie - Substanzklassen / Wirkmechanismen - Typische chirurgisch-intensivmedizinische Infektionen - Therapieversager - Perioperative Antibiotikaprophylaxe - Antibiotikatherapie bei Niereninsuffizienz und Nierenersatztherapie - Antiinfektive Therapie in der Schwangerschaft und Stillzeit - Antiinfektive Therapie bei Kindern und Jugendlichen - Antiinfektive Therapie bei Übergewichtigen -Therapiekosten

An intra-abdominal hypertension (IAH) defined as a pathological increase in intra-abdominal pressure (IAP) is commonly found on ICU admission or during the ICU stay. Several studies confirmed that an IAH is an independent predictor for mortality of critically ill patients. The abdominal compartment syndrome (ACS) which is defined as a sustained IAP>20 mmHg (with or without an abdominal perfusion pressure [APP]

Eine mogliche Ursache fur Fieber unklarer Genese („fever of unknown origin“, FUO) ist das maligne neuroleptische Syndrom (MNS). Das MNS ist eine potenziell letale Nebenwirkung verschiedener Medikamente, u. a. der Neuroleptika. Die typischen Leitsymptome sind die Entwicklung von schwerem Rigor und Temperaturerhohung in Verbindung mit neuroleptischer Medikation. Im Fallbeispiel wird uber einen Patienten mit einer schizoaffektiven Storung berichtet, bei dem die Diagnose des MNS initial nicht eindeutig war. Letztlich konnten bei Fieber und einer massiv erhohten Kreatinkinase(CK)-Konzentration als Zeichen einer Muskelschadigung die Diagnose gestellt und eine adaquate Therapie mit Dantrolen, Bromocriptin und Amantadin eingeleitet werden.

Indocyanine green (ICG) is a water-soluble dye that is bound to plasma proteins when administered intravenously and nearly completely eliminated from the blood by the liver. ICG elimination depends on hepatic blood flow, hepatocellular function and biliary excretion. ICG elimination is considered as a useful dynamic test describing liver function and perfusion in the perioperative setting, i.e., in liver surgery and transplantation, as well as in critically ill patients. ICG plasma disappearance rate (ICG-PDR) which can be measured today by transcutaneous systems at the bedside is a valuable method for dynamic assessment of liver function and perfusion, and is regarded as a valuable prognostic tool in predicting survival of critically ill patients, presenting with sepsis, ARDS or acute liver failure.

Background Real-time ultrasound (US) in central venous catheterization is superior to pre-procedure US. However, moving real-time US into routine practice is impeded by its perceived expense and difficulty. Currently, pre-procedure US and landmark (LM) methods are most widely used. We investigated these techniques in internal jugular vein (IJV) catheterization in respect of operator experience, complications, and risk factors. Methods In an observational non-randomized study, we investigated 606 of ∼1300 procedures, that is, 200 patients were treated under pre-procedure US and 406 under LM [pathfinder (PF) n =202, direct cannulation (DC) n =204]. We recorded first needle pass success rate, success rate after the third attempt, and the cannulation time. Procedures were performed by inexperienced ( 100 catheterizations) operators. Results Pre-procedure US was associated with more successful attempts and shorter cannulation times. Under pre-procedure US, 88% of first attempts were successful and 100% of third attempts. The median (range) cannulation time was 39 (10–330) s. Under PF, only 56% of first, and 87% of third, attempts were successful with a median (range) cannulation time of 100 (25–3600) s. Under DC, 61% of first and 89% of third attempts were successful; the median (range) cannulation time was 70 (10–3600) s. Remarkably, inexperienced operators using pre-procedure US ( n =38) were significantly faster than experienced operators using PF or DC ( n =343) (cannulation time: median 60 s, range 12–330, for inexperienced; 60 s, range 10–3600, for experienced). First puncture success rates were higher (pre-procedure US, inexperienced 84%, PF or DC, experienced 57%). Conclusions Pre-procedure US for IJV catheterization is safe, quick, and superior to LM.

Medikamenteninteraktionen sind ein haufiges Problem bei alteren multimorbiden Patienten, die eine Polymedikation aufweisen, denn mit der Anzahl der verordneten Medikamente steigt auch das Risiko fur unerwunschte Wirkungen und Interaktionen zwischen Arzneimitteln. Da an der Arzneimitteltherapie kritisch kranker Patienten medizinische und pharmazeutische Akteure beteiligt sind, wird es in den kommenden Jahren von entscheidender Bedeutung sein, diese als eine gemeinsameAufgabe zu begreifen. Von dieser Zusammenarbeit wird es abhangen, mit den zur Verfugung stehenden Ressourcen das optimale Ergebnis fur den Patienten zu erzielen. Grundsatzlich konnen Medikamenteninteraktionen auf pharmakokinetischen und pharmakodynamischen Aspekten beruhen. Pharmakokinetische Medikamenten-interaktionen betreffen die Beeinflussung der Cytochrom-P450-Enzyme und der Transportproteine im Korper. Pharmakodynamische Interaktionen sind zum Beispiel als additive Effekte zu finden. Dazu zahlt sehr haufig das additive Risiko der QT-Zeit-Verlangerung, wenn Substanzen kombiniert werden, die bereits alleine diese unerwunschte Wirkung hervorrufen konnen. Die Bedeutung beider Aspekte sollte bei der Medikation entsprechend berucksichtigt und ein moglicher negativer Einfluss vermieden werden.

Larynxverletzungen sind seltene, potentiell lebensbedrohliche Verletzungen. Aufgrund der Topographie sind Begleitverletzungen der grosen Halsgefase, der zervikalen Nerven, der Thoraxorgane oder des Ruckenmarks haufig. Daher gilt es in der initialen Diagnostik, diese die Prognose bestimmenden Verletzungen auszuschliesen. Es zeigte sich ein Patient mit ventraler Perforation des Kehlkopfes, initialer Dyspnoe, Bluterbrechen und Hautemphysem am Hals links. In Zusammenschau der Befunde wurde im interdisziplinaren Konsens eine konservative Therapie festgelegt.