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Perfluorocarbons are oxygen-carrying, dense liquids initially intended for the use in partial or total liquid ventilation in patients with severe acute respiratory distress syndrome (ARDS), but did not show beneficial effects in clinical studies. However, perfluorocarbons may be used for lung lavage in severe alveolar proteinosis. In ARDS, oxygenation may be so severely compromised that the use of non-oxygenated perfluorocarbons may not be possible. We report of a case of severe non-resolving ARDS treated with extracorporeal membrane oxygenation (ECMO) to secure oxygenation, using perfluorocarbon in a single instillation to aid the clearance of debris and proteinacous edema.

The value of positive end-expiratory pressure (PEEP) in maintaining oxygenation during ventilation with a laryngeal mask airway (LMA) mask is unclear. To clarify the potential benefit or harm to PEEP application during positive pressure ventilation with a ProSeal LMA® mask, we compared the effect of PEEP versus zero end-expiratory pressure (ZEEP) on gas leakage and oxygenation. We hypothesized that a PEEP of 8 mbar (8.2 cm H 2 O) would be associated with an increased incidence of gas leakage compared to ZEEP.We designed a prospective, controlled, randomized, single-blinded, multicenter clinical trial. Patients18 years of age with an American Society of Anesthesiologists (ASA) physical status I/II without increased risk of aspiration were enrolled if they were scheduled for elective surgery under general anesthesia with an LMA mask. Patients were randomized to a control group managed with ZEEP or an intervention group managed with a PEEP of 8 mbar. Both groups received positive pressure ventilation. The primary end point was the occurrence of gas leakage. The Student t test and χ 2 test were used for statistical analysis.A total of 174 patients were enrolled in the ZEEP group, and 208 were enrolled in the PEEP group. The incidence of gas leakage did not differ between the 2 groups (ZEEP: 23/174, 13.2%; PEEP: 42/208, 20.2%; P = .071; odds ratio [OR], 1.611; 95% confidence interval [CI], 0.954-2.891). However, more patients required reseating of the LMA mask in the PEEP group (ZEEP: 5/174, 2.9%; PEEP: 18/208, 8.7%; P = .018; OR, 3.202; 95% CI, 1.164-8.812). The need for endotracheal intubation did not differ between groups (ZEEP: 2/174, 1.1%; PEEP: 7/208, 3.4%; P = .190; OR, 2.995; 95% CI, 0.614-14.608). After positive pressure ventilation for 25 minutes, the mean peripheral oxygen saturation (Sp o2 ) was higher in the PEEP than in the ZEEP group (98.5 [1.9]% vs 98.0 [1.4]%; P = .01). Peak inspiratory pressure (PIP; 16 [2] vs 12 [4] mbar; P.001) and dynamic compliance (57 [14] vs 49 [14] mL/mbar; P.001) were both higher in the PEEP group than in the ZEEP group.Use of PEEP did not affect the overall incidence of gas leakage. However, PEEP did result in a higher incidence of attempts to reseat the LMA mask compared to ZEEP, whereas the incidence of rescue intubation did not differ between groups. We concluded that a PEEP of 8 mbar did not increase overall gas leakage during positive pressure ventilation with an LMA mask, but it did slightly improve gas exchange and compliance. Overall, our study does not provide strong arguments for using PEEP during ventilation with an LMA mask in elective surgery.

ObjectiveCachexia and nutritional problems play a major role in palliative care. Artificial nutrition such as parenteral nutrition is common but its role and indications in terminal patients remain controversial due to lack of data. Therefore, recommendations are vague. Benefits and risks of parenteral nutrition in palliative care as well as the clinical implementation of the guidelines have not been adequately studied yet.MethodsIn this single-centre observational study, 72 palliative care patients were followed for 1 month. Patients with and without parenteral nutrition were analysed regarding venous access complications, oedema, weight and health-related quality of life.Results93% of all patients showed reduced food intake. 34 (47%) patients received parenteral nutrition. Parenteral nutrition reduced energy deficit but was not associated with quality of life. Complications with the venous accesses for parenteral nutrition were frequent. A relevant proportion of patients with planned parenteral nutrition received no or only a few days of parenteral nutrition. Moreover, patients with parenteral nutrition showed more frequent and pronounced oedema.ConclusionThe benefit–risk balance of palliative parenteral nutrition in end-of-life treatment seems to be questionable. In view of the identified risks, parenteral nutrition in end-of-life care should be initiated with caution.

Background: End-of-life care (EOLC) in the intensive care unit (ICU) is becoming increasingly more common but ethical standards are compromised by growing economic pressure. It was previously found that perception of non-beneficial treatment (NBT) was independently associated with the core burnout dimension of emotional exhaustion. It is unknown whether factors of the work environment also play arole in the context of EOLC.Objective: Is the working environment associated with perception of NBT or clinician burnout?Material and Methods: Physicians and nursing personnel from 11 German ICUs who took part in an international, longitudinal prospective observational study on EOLC in 2015-2016 were surveyed using validated instruments. Risk factors were obtained by multivariate multilevel analysis.Results: The participation rate was 49.8% of personnel working in the ICU at the time of the survey. Overall, 325 nursing personnel, 91residents and 26consulting physicians participated. Nurses perceived NBT more frequently than physicians. Predictors for the perception of NBT were profession, collaboration in the EOLC context, excessively high workload (each p0.001) and the numbers of weekend working days per month (p=0.012). Protective factors against burnout included intensive care specialization (p=0.001) and emotional support within the team (p0.001), while emotional exhaustion through contact with relatives at the end of life and a high workload were both increased (each p0.001).Discussion: Using the example of EOLC, deficits in the work environment and stress factors were uncovered. Factors of the work environment are associated with perceived NBT. To reduce NBT and burnout, the quality of the work environment should be improved and intensive care specialization and emotional support within the team enhanced. Interprofessional decision-making among the ICU team and interprofessional collaboration should be improved by regular joint rounds and interprofessional case discussions. Mitigating stressful factors such as communication with relatives and high workload require allocation of respective resources.

Background Photodynamic inactivation (PDI) is a promising approach to treat multidrug-resistant infections. However, effectiveness of PDI is limited, particularly in Gram-negative bacteria. The use of photosensitizer (PS) 3,3′,3′′,3′′′-(7,8,17,18-tetrahydro-21H,23H-porphyrine-5,10,15,20-tetrayl)tetrakis[1-methyl-pyridinium]tetratosylate (THPTS) and laser light has led to very promising results. This study focuses on the effects of THPTS in various critical multidrug-resistant bacterial strains and explores the possibility of light-emitting diode (LED)-based activation as a clinically more feasible alternative to laser light. Methods THPTS was further chemically characterized and in vitro testing of PDI of different multidrug-resistant bacterial strains was performed under various experimental conditions, including varying drug concentration, incubation time, light source (laser and LED) and light intensity, by determination of viable bacteria after treatment. The effect of hyaluronic acid as an adjuvant for medical applications was also evaluated. Results Bacterial density of all investigated bacterial strains was reduced by several orders of magnitude, irrespective of multidrug-resistance or hyaluronic acid addition. The effect was less intense in Gram-negative strains (disinfection), and more pronounced in Gram-positive strains (sterilization), even at reduced THPTS concentrations or decreased light treatment intensity. Controls without THPTS or without light treatment did not indicate reduced bacterial density. Conclusions PDI with THPTS and laser light was effective in all investigated bacterial strains. Gram-negative strains were less, but sufficiently, susceptible to PDI. Adding hyaluronic acid did not reduce the antibacterial treatment effect. LED-based PDI is equally effective when illumination duration is increased to compensate for reduced light intensity.

Introduction Hemoglobin-based oxygen carriers (HBOC) have been developed as an alternative to blood transfusions . Their nitric-oxide-scavenging properties HBOC also induce vasoconstriction . In acute lung injury , an excess of nitric oxide results in a general vasodilation , reducing oxygenation by impairing the hypoxic pulmonary vasoconstriction . Inhaled nitric oxide (iNO) is used to correct the ventilation perfusion mismatch . We hypothesized that the additional use of HBOC might increase this effect. In a rodent model of ARDS we evaluated the combined effect of HBOC and iNO on vascular tone and gas exchange. Methods ARDS was induced in anaesthetized Wistar rats by saline lavage and aggressive ventilation. Two groups received either hydroxyethylstarch 10% (HES; n = 10) or the HBOC hemoglobin glutamer-200 (HBOC-200; n = 10) via a central venous infusion . Additionally, both groups received iNO. Monitoring of the right ventricular pressure (RVP) and mean arterial pressure (MAP) was performed with microtip transducers. Arterial oxygenation was measured via arterial blood gas analyses. Results Application of HBOC-200 led to a significant increase of MAP and RVP when compared to baseline and to the HES group. This effect was reversed by iNO. The application of HBOC and iNO had no effect on the arterial oxygenation over time. No difference in arterial oxygenation was found between the groups. Conclusion Application of HBOC led to an increase of systemic and pulmonary vascular resistance in this animal model of ARDS. The increase in RVP was reversed by iNO. Pulmonary vasoconstriction by hemoglobin glutamer-200 in combination with iNO did not improve arterial oxygenation in ARDS.

The laryngeal tube suction II (LTS II) is a supraglottic airway device (SAD) with a gastric drainage tube and enhanced seal properties as compared with other SADs. Therefore, its use has been proposed in situations with an elevated risk of aspiration.To compare the safety and efficacy of airway management and controlled mechanical ventilation when using either an LTS II or an endotracheal tube for laparoscopic radical prostatectomy.Randomised, controlled, blinded and single-centre study.Academic tertiary care centre in Leipzig from April 2014 to May 2015.It was planned to include 100 patients but the study was stopped after 50 patients following an interim analysis. These 50 patients were randomised to either the LTS II group or the endotracheal tube group. All male patients aged more than 18 years for elective laparoscopic radical prostatectomy were eligible. Exclusion criteria included a BMI more than 30, American Society of Anesthesiologists class III or greater, a history of gastroesophageal reflux or other factors known to increase the risk of aspiration and a known difficult airway.All patients received general anaesthesia. Airway management was with either a LTS II or an endotracheal tube, according to the randomisation.The primary endpoint was successful insertion of the particular airway device during anaesthesia for laparoscopic radical prostatectomy.In 15 of the 28 patients randomised to LTS II, the device had to be removed and an endotracheal tube inserted, mainly because of an airway leak (n = 10) or swelling of the tongue (n = 3). Ventilation was successful in all patients (n = 22) randomised to endotracheal tube. Quality of ventilation was rated better in the endotracheal tube group.Our data suggest that LTS II should not be the preferred method of airway management in patients undergoing laparoscopic radical prostatectomy.DRKS00008985 (German Clinical Trials Register).

Die intranasale Applikation von Medikamenten zur Erzielung eines relevanten systemischen Plasmaspiegels wurde bereits vor rund 20 Jahren beschrieben. Die intranasale Medikamentenapplikation ist insbesondere durch eine geringe Invasivitat bei gleichzeitig gunstiger Pharmakokinetik gekennzeichnet und kann vor allem bei Kindern und bei Patienten mit schwierigen Venenverhaltnissen eine sinnvolle Alternative zur intravenosen oder intraossaren Medikamentengabe in der Notfallmedizin darstellen. Die intranasale Medikamentengabe findet auserdem eine hohe Akzeptanz bei medizinischem Personal. In den letzten Jahren wurden verschiedene Medikamente auf ihre Eignung zur intranasalen Applikation uberpruft. Insbesondere die Moglichkeit der Initialtherapie zerebraler Krampfanfalle, der Analgosedierung sowie die intranasale Therapie der Opiatuberdosierung sind dabei attraktiv.

In patients with severely compromised gas exchange, interhospital transportation is frequently necessary due to the need to provide access to specialized care. Risks are inherent during transport, so the anticipated benefits of transportation must be weighed against the possible negative outcome during the transport. The use of specialized teams during transportation can help to reduce adverse events. Diligent planning of the transportation, monitoring and medical staff during transport can decrease adverse events and reduce risks. This article defines the group of patients that may benefit from referral. This article discusses the risks associated with the transportation of patients with severely impaired gas exchange and the risks related to different means of transportation. The decisions required before transportation are described as well as the practical approach starting at the transferring hospital until arrival at the admitting hospital.

Background Significant long-term reduction in health-related quality of life (HRQoL) is often observed in survivors of the acute respiratory distress syndrome (ARDS), and return to work (RtW) is limited. There is a paucity of data regarding the relationship between the quality of care (QoC) in the intensive care unit (ICU) and both HRQoL and RtW in ARDS survivors. Therefore, the aim of our study was to investigate associations between indicators of QoC and HRQoL and RtW in a cohort of survivors of ARDS. Methods To determine the influence of QoC on HRQoL and RtW 1 year after ICU-discharge, ARDS patients were recruited into a prospective multi-centre patient cohort study and followed up regularly after discharge. Patients were asked to complete self-report questionnaires on HRQoL (Short Form 12 physical component scale (PCS) and mental component scale (MCS)) and RtW. Indicators of QoC pertaining to volume, structural and process quality, and general characteristics were recorded on ICU level. Associations between QoC indicators and HrQoL and RtW were investigated by multivariable linear and Cox regression modelling, respectively. B values and hazard ratios (HRs) are reported with corresponding 95% confidence intervals (CIs). Results 877 (of initially 1225 enrolled) people with ARDS formed the DACAPO survivor cohort, 396 were finally followed up to 1 year after discharge. The twelve-month survivors were characterized by a reduced HRQoL with a greater impairment in the physical component (Md 41.2 IQR [34–52]) compared to the mental component (Md 47.3 IQR [33–57]). Overall, 50% of the patients returned to work. The proportion of ventilated ICU patients showed significant negative associations with both 12 months PCS (B = − 11.22, CI −20.71; − 1,74) and RtW (HR = 0,18, CI 0,04;0,80). All other QoC indicators were not significantly related to outcome. Conclusions Associations between ICU QoC and long-term HrQoL and RtW were weak and largely non-significant. Residual confounding by case mix, treatment variables before or during ICU stay and variables pertaining to the post intensive care period (e.g. rehabilitation) cannot be ruled out. Trial registration Clinicaltrials.govNCT02637011. (December 22, 2015, retrospectively registered)

Die supraglottischen Atemwegshilfen (Larynxmaske, Larynxtubus) haben nach wie vor einen klaren Stellenwert im Algorithmus des erwartet und unerwartet schwierigen Atemwegs. Die Datenlage zum prahospitalen bzw. auserklinischen Atemwegsmanagement ist heterogen und teilweise widerspruchlich. Der vorliegende Beitrag diskutiert die Anwendung des Larynxtubus in der praklinischen Notfallmedizin kritisch und zeigt zum einen klare Vorteile, aber auch Nachteile bei seiner Verwendung auf. Die Pro-Gruppe vertritt die Meinung, dass in der Hand des erfahrenen Anwenders der Larynxtubus aktuell und weiterhin eine wertvolle Alternative zur endotrachealen Intubation beim prahospitalen Management des schwierigen Atemwegs ist, auf die derzeit nicht verzichtet werden sollte. Die Kontra-Gruppe weist auf mehrere Studien hin, die eine hohe Komplikationsrate bei Verwendung des Larynxtubus zeigen. Angesichts dessen sei der Einsatz des Larynxtubus bei der Reanimation auserhalb einer strengen Indikationsstellung derzeit kritisch zu werten.

Background Emergency airway management (AM) is a major key for successful resuscitation of critically ill non-traumatic (CINT) patients. Details of the AM of these patients in German emergency departments (ED) are unknown. This observational study describes epidemiology, airway techniques, success rates and complications of AM in CINT ED patients in the resuscitation room (RR). Methods Data was collected prospectively on adult CINT patients admitted to the RR of a single German university ED September 2014 to August 2015. Patient characteristics, out-of-hospital and in-hospital RR AM, complications and success rates were recorded using a self-developed airway registry form. Results During the study period 34,303 patients were admitted to the ED, out of those 21,074 patients for non-trauma emergencies. Suffering from severe acute life-threatening problems, 532 CINT patients were admitted to the RR. 150 (28.2%) CINT patients had received out-of-hospital AM. In 16 of these cases (10.7%) the inserted airway needed to be changed after RR admission (unrecognized oesophageal intubation: n = 2, laryngeal tube exchange: n = 14). 136 (25.6%) CINT patients without out-of-hospital AM received RR AM immediately after admission. The first-pass and overall success rate in the RR were 71 and 100%, respectively, and multiple intubation attempts were necessary in 29%. A lower Cormack/Lehane (C/L) grade was associated with less intubation attempts (C/L1/2 vs. 3/4: 1.2 ± 0.5 vs. 1.8 ± 1.2, p = 0.0002). Complication rate was 43%. Conclusions OcEAN demonstrates the challenges of AM in CINT patients in a German ED RR. We propose a nation-wide ED airway registry to better track outcomes in the future. Electronic supplementary material The online version of this article (10.1186/s13049-019-0599-1) contains supplementary material, which is available to authorized users.

Fur Patienten mit schwerem akuten Lungenversagen (ARDS) konnte ein signifikanter Uberlebensvorteil bei der Durchfuhrung von Bauchlagerungen gezeigt werden. Auch Patienten, die mit einer extrakorporalen Membranoxygenierung (ECMO) behandelt werden, konnten davon profitieren. Die Lagerung ist jedoch mit einem potenziell erhohten Risiko schwerer lagerungsbedingter Komplikationen vergesellschaftet. In dieser Studie sollen die Machbarkeit und die Sicherheit der intermittierenden Bauchlage fur Patienten mit schwerem ARDS unter laufender ECMO-Therapie untersucht werden. Wir untersuchten retrospektiv alle Patienten, die zwischen Januar 2009 und August 2013 auf der Interdisziplinaren Operativen Intensivstation des Universitatsklinikums Leipzig mit venovenoser (vv)ECMO und Bauchlage behandelt wurden. Basisdaten, Krankenhausletalitat und schwere Zwischenfalle wurden erfasst. Als schwere Zwischenfalle wurden Dislokationen oder Obstruktionen von Atemwegszugangen, ECMO-Kanulen und ein Herz-Kreislauf-Stillstand definiert. Ergebnisse werden als Median (1. Quartile; 3. Quartile) angegeben. Es wurden 26 Patienten mit ECMO-Therapie und Bauchlage behandelt. Ursachen des ARDS waren Pneumonien (n = 20), Aspirationen (n = 2) und in 4 Fallen andere seltenere Grunde. Die 26 Patienten wurden 8 (6;11) Tage mit ECMO behandelt. In dieser Zeit fuhrten wir insgesamt 134 Bauchlagerungen durch. Jeder Patient erfuhr im Mittel 5 (3;7) Lagerungsphasen fur jeweils 12 (8;12) h. Wir konnten keine schweren Zwischenfalle feststellen. Die Krankenhausletalitat betrug 42 %, die Letalitat unter ECMO 35 %. Bei Patienten mit ECMO-Therapie bei schwerem ARDS fanden wir bei der Anwendung von Bauchlage keine schwerwiegenden Zwischenfalle.

Zusammenfassung Viele Einsatze in der praklinischen Notfallrettung erscheinen den Rettern als „Fehleinsatze“ oder falsche Indikationen im Sinne der Landesrettungsgesetze. Solche Einsatze werden oftmals durch soziale Aspekte getriggert, oder diese stehen gar im Vordergrund des Einsatzes. Mitarbeiter der Rettungsdienste werden mit sozialen Problemen konfrontiert und fuhlen sich in der Folge haufig damit allein gelassen. Der vorliegende Beitrag fordert das Verstandnis der Rettungsdienstmitarbeiter fur die Zusammenhange zwischen gesellschaftlichen Problemen und Gesundheit. Fur haufige soziale Notfalle im Rettungsdienst werden Losungsstrategien angeboten. In dieser Arbeit werden Zusammenhange zwischen soziookonomischem Status und Gesundheit bzw. Krankheit aufgezeigt. Typische Einsatzindikationen, bei denen soziale Aspekte eine grose Rolle spielen, werden dargestellt und Losungsstrategien fur das Vorgehen vorgeschlagen. Diskutiert wird der Umgang mit Fallen von Kindesmisshandlung und hauslicher Gewalt. Drei klassische psychiatrische Problematiken mit haufig sozialer Komponente werden erortert: psychomotorische Erregungszustande, Suizide und alkoholassoziierte Einsatze. Hier wird besonders auf Fremdgefahrdung und aggressive Patienten eingegangen. Gerade bei alteren und chronisch-kranken Patienten spielen neben der Behandlung medizinischer Fragen soziale Probleme eine wichtige Rolle. Die Moglichkeiten des Rettungsteams zur Losung sozialer Probleme sind in aller Regel stark begrenzt. Es ist fur das Rettungsteam jedoch wichtig, die Strukturen und nichtmedizinischen Ansprechpartner in der eigenen Region zu kennen und zielgerichtet an sie zu verweisen. Dazu gehoren Sozialdienste, Jugendamter; Kriseninterventionsteams oder beispielsweise sozialpsychiatrische Dienste. Many missions in the preclinical emergency services seem to be triggered by false indications as defined by the Federal State Rescue Act. These emergency calls are often a result of or associated with social issues. Emergency rescue personnel are confronted with social problems and as a result often feel left alone with the problem. This article promotes the understanding of emergency service personnel for the associations between social problems and health. Solution strategies for frequent social emergencies are described. This article demonstrates the associations between socioeconomic status, health and disease. Typical indications for missions in which social aspects play an important role are presented and solution strategies for the approach are suggested. A discussion is presented on how to deal with cases of child abuse and domestic violence. Three classical psychiatric problem areas with common social components are explained: psychomotor state of excitation, suicide and alcohol-associated incidents and special attention is paid to danger to third parties and aggressive patients. In addition to the treatment of medical conditions, social problems play an important role particularly for the elderly and chronically ill patients. Emergency personnel have only limited options for dealing with such problems; however, it is important to be aware of regional structures and non-medical organizations, which might be of help in such situations. These include social services, youth welfare services, crisis interventions teams and social psychiatric services.

Purpose While most research focuses on the association between medical characteristics and residual morbidity of survivors of the acute respiratory distress syndrome (ARDS), little is known about the relation between potentially modifiable intensive care unit (ICU) features and the course of health-related quality of life (HRQoL). Accordingly, the DACAPO study was set up to elucidate the influence of quality of intensive care on HRQoL and return to work (RtW) in survivors of ARDS. The continued follow-up of these former ICU patients leads to the establishment of the DACAPO (survivor) cohort. Participants Sixty-one ICUs all over Germany recruited patients with ARDS between September 2014 and April 2016. Inclusion criteria were: (1) age older than 18 years and (2) ARDS diagnosis according to the ‘Berlin definition’. No further inclusion or exclusion criteria were applied. 1225 patients with ARDS could be included in the DACAPO ICU sample. Subsequently, the 876 survivors at ICU discharge form the actual DACAPO cohort. Findings to date The recruitment of the participants of the DACAPO cohort and the baseline data collection has been completed. The care-related data of the DACAPO cohort reveal a high proportion of adverse events (in particular, hypoglycaemia and reintubation). However, evidence-based supportive measures were applied frequently. Future plans Three months, 6 months and 1 year after ICU admission a follow-up assessment is conducted. The instruments of the follow-up questionnaires comprise the domains: (A) HRQoL, (B) RtW, (C) general disability, (D) psychiatric symptoms and (E) social support. Additionally, an annual follow-up of the DACAPO cohort focusing on HRQoL, psychiatric symptoms and healthcare utilisation will be conducted. Furthermore, several add-on projects affecting medical issues are envisaged. Trial registration number NCT02637011.

Viele Einsatze in der praklinischen Notfallrettung erscheinen den Rettern als „Fehleinsatze“ oder falsche Indikationen im Sinne der Landesrettungsgesetze. Solche Einsatze werden oftmals durch soziale Aspekte getriggert, oder diese stehen gar im Vordergrund des Einsatzes. Mitarbeiter der Rettungsdienste werden mit sozialen Problemen konfrontiert und fuhlen sich in der Folge haufig damit allein gelassen. Der vorliegende Beitrag fordert das Verstandnis der Rettungsdienstmitarbeiter fur die Zusammenhange zwischen gesellschaftlichen Problemen und Gesundheit. Fur haufige soziale Notfalle im Rettungsdienst werden Losungsstrategien angeboten. In dieser Arbeit werden Zusammenhange zwischen soziookonomischem Status und Gesundheit bzw. Krankheit aufgezeigt. Typische Einsatzindikationen, bei denen soziale Aspekte eine grose Rolle spielen, werden dargestellt und Losungsstrategien fur das Vorgehen vorgeschlagen. Diskutiert wird der Umgang mit Fallen von Kindesmisshandlung und hauslicher Gewalt. Drei klassische psychiatrische Problematiken mit haufig sozialer Komponente werden erortert: psychomotorische Erregungszustande, Suizide und alkoholassoziierte Einsatze. Hier wird besonders auf Fremdgefahrdung und aggressive Patienten eingegangen. Gerade bei alteren und chronisch-kranken Patienten spielen neben der Behandlung medizinischer Fragen soziale Probleme eine wichtige Rolle. Die Moglichkeiten des Rettungsteams zur Losung sozialer Probleme sind in aller Regel stark begrenzt. Es ist fur den Notarzt jedoch wichtig, die Strukturen und nichtmedizinischen Ansprechpartner in der eigenen Region zu kennen und zielgerichtet an sie zu verweisen. Dazu gehoren Sozialdienste, Jugendamter; Kriseninterventionsteams oder beispielsweise sozialpsychiatrische Dienste.

Recommendations concerning the management of hemoglobin levels and hematocrit in patients on extracorporeal membrane oxygenation (ECMO) still advise maintenance of a normal hematocrit. In contrast, current transfusion guidelines for critically ill patients support restrictive transfusion practice. We report on a series of patients receiving venovenous ECMO (vvECMO) for acute respiratory distress syndrome (ARDS) treated according to the restrictive transfusion regimen recommended for critically ill patients. We retrospectively analyzed 18 patients receiving vvECMO due to severe ARDS. Hemoglobin concentrations were kept between 7 and 9 g/dL with a transfusion trigger at 7 g/dL or when physiological transfusion triggers were apparent. We assessed baseline data, hospital mortality, time on ECMO, hemoglobin levels, hematocrit, quantities of packed red blood cells received, and lactate concentrations and compared survivors and nonsurvivors. The overall mortality of all patients on vvECMO was 38.9%. Mean hemoglobin concentration over all patients and ECMO days was 8.30 ± 0.51 g/dL, and hematocrit was 0.25 ± 0.01, with no difference between survivors and nonsurvivors. Mean numbers of given PRBCs showed a trend towards higher quantities in the group of nonsurvivors, but the difference was not significant (1.97 ± 1.47 vs. 0.96 ± 0.76 units; P = 0.07). Mean lactate clearance from the first to the third day was 45.4 ± 28.3%, with no significant difference between survivors and nonsurvivors (P = 0.19). In our cohort of patients treated with ECMO due to severe ARDS, the application of a restrictive transfusion protocol did not result in an increased mortality. Safety and feasibility of the application of a restrictive transfusion protocol in patients on ECMO must further be evaluated in randomized controlled trials.

Background From July 2010-April 2013, Leipzig University Hospital experienced the largest outbreak of a Klebsiella pneumoniae carbapenemase 2 (KPC-2)-producing Klebsiella pneumoniae (KPC-2- Kp ) strain observed in Germany to date. After termination of the outbreak, we aimed to reconstruct transmission pathways by phylogenetics based on whole-genome sequencing (WGS). Methods One hundred seventeen KPC-2- Kp isolates from 89 outbreak patients, 5 environmental KPC-2- Kp isolates, and 24 K pneumoniae strains not linked to the outbreak underwent WGS. Phylogenetic analysis was performed blinded to clinical data and based on the genomic reads. Results A patient from Greece was confirmed as the source of the outbreak. Transmission pathways for 11 out of 89 patients (12.4%) were plausibly explained by descriptive epidemiology, applying strict definitions. Five of these and an additional 15 (ie, 20 out of 89 patients [22.5%]) were confirmed by phylogenetics. The rate of phylogenetically confirmed transmissions increased significantly from 8 out of 66 (12.1% for the time period before) to 12 out of 23 patients (52.2% for the time period after; P .001) after implementation of systematic screening for KPC-2- Kp (33,623 screening investigations within 11 months). Using descriptive epidemiology, systematic screening showed no significant effect (7 out of 66 [10.6%] vs 4 out of 23 [17.4%] patients; P = .465). The phylogenetic analysis supported the assumption that a contaminated positioning pillow served as a reservoir for the persistence of KPC-2- Kp . Conclusions Effective phylogenetic identification of transmissions requires systematic microbiologic screening. Extensive screening and phylogenetic analysis based on WGS should be started as soon as possible in a bacterial outbreak situation.

BACKGROUND: The modalities of tracheostomy for critically ill patients are still controversially discussed. Although the use of percutaneous dilatational tracheostomy (PDT) is generally accepted to be a safe procedure, it is still not considered to be suitable for patients requiring a permanent tracheostomy. METHODS: This was an observational cohort study investigating long-term outcome parameters of PDT. All patients having received a PDT at the interdisciplinary ICU at the University of Leipzig between October 2008 and August 2009 that survived to discharge were asked for consent to participate (n = 103). Baseline data, admitting diagnosis, reasons for tracheostomy, and timing for tracheostomy were recorded. Subjects and medical providers were asked for neurological outcome, adverse events, and personal discomfort related to the tracheostomy. The study period was 2 y from the time of tracheostomy. RESULTS: Seventy-one subjects were finally included in the survey. Data of 8 subjects (11%) were incomplete. Reasons for tracheostomy were the need for long-term ventilation (42%), weaning (31%), and neurological deficits (27%). No severe adverse events were registered. Sixty-five percent of all subjects could finally be decannulated. Two subjects remained with their initial tracheostomy, and in 5 subjects (7%) tracheostomy was modified to a surgical tracheostomy. Thirty-seven percent of subjects died during the 2 y. Twenty-five of the surviving subjects (35%) had only minor or moderate neurological and psychological deficits. Complaints were mostly connected to swallowing and breathing. CONCLUSIONS: Decannulations after PDT are easily done. Complications after PDT requiring a transformation to a surgical tracheostomy are rare. Elective surgical conversions are not necessary.

The in-hospital spread of automated external defibrillators (AEDs) is aimed to allow for a shock-delivery within three minutes. However, it has to be questioned if the implementation of AED alone really contributes to a ‘heart-safe hospital’. We performed a cohort study of 1008 in-hospital emergency calls in a university tertiary care hospital, analysing cardiopulmonary resuscitation (CPR) cases with and without AED use. In total, 484 patients (48%) had cardiac arrest and received CPR. Response time of the emergency team was 4.3 ± 4.0 minutes. Only 8% percent of the CPR cases had a shockable rhythm. In three of 43 placements a shock was delivered by the AED. There were no differences in survival between patients with CPR only and CPR with AED use. Our data do not support the use of an AED for in-hospital CPR if a professional response team is rapidly available.

A 33-years-old male patient presented with cardiac arrhythmias, acute shock and multiple organ dysfunction after the surgical removal of a massive epidermoid posterior to the brainstem. The patient initially presented with paraesthesia along the right C6 dermatome due to a big tumour at the brain stem. Surgical removal was performed without adverse events and he was transferred to our intensive care unit (ICU) immediately after the operation. Though initially showing a stable postsurgical course he developed cardiac arrhythmias and a state of acute distributive shock with consecutive multi organ failure. Extensive diagnostic measures could not identify a specific cause for this rapid deterioration. However, under carefully monitored symptomatic therapy the patient improved quickly, was extubated 72 h after admission and discharged from the ICU 6 days later. The follow-up did not show any persisting neurological deficits and no evidence of a residual tumour in the MRI-study.

Hintergrund Das im Januar 2014 in Kraft getretene Notfallsanitatergesetz regelt die Ausbildung des Rettungsdienstpersonals grundlegend neu. In der nun dreijahrigen Ausbildung werden 720 h praktische Ausbildung in geeigneten Krankenhausern gefordert. Es existiert jedoch bis dato wenig Erfahrung, wie die Inhalte der Ausbildungs- und Prufungsverordnung in den Krankenhausern sinnvoll umgesetzt werden konnen.

Early optimization of fluid status is of central importance in the treatment of critically ill patients. This study aims to investigate whether inferior vena cava (IVC) diameters correlate with invasively assessed hemodynamic parameters and whether this approach may thus contribute to an early, non-invasive evaluation of fluid status. Thirty mechanically ventilated patients with severe sepsis or septic shock (age 60 +/- 15 years; APACHE-II score 31 +/- 8; 18 male) were included. IVC diameters were measured throughout the respiratory cycle using transabdominal ultrasonography. Consecutively, volume-based hemodynamic parameters were determined using the single-pass thermal transpulmonary dilution technique. This was a prospective study in a tertiary care academic center with a 24-bed medical intensive care unit (ICU) and a 14-bed anesthesiological ICU. We found a statistically significant correlation of both inspiratory and expiratory IVC diameter with central venous pressure (p = 0.004 and p = 0.001, respectively), extravascular lung water index (p = 0.001, p0.001, respectively), intrathoracic blood volume index (p = 0.026, p = 0.05, respectively), the intrathoracic thermal volume (both p0.001), and the PaO(2)/FiO(2) oxygenation index (p = 0.007 and p = 0.008, respectively). In this study, IVC diameters were found to correlate with central venous pressure, extravascular lung water index, intrathoracic blood volume index, the intrathoracic thermal volume, and the PaO(2)/FiO(2) oxygenation index. Therefore, sonographic determination of IVC diameter seems useful in the early assessment of fluid status in mechanically ventilated septic patients. At this point in time, however, IVC sonography should be used only in addition to other measures for the assessment of volume status in mechanically ventilated septic patients.

The acute respiratory distress syndrome (ARDS) is characterized by a maldistribution of pulmonary blood flow towards non-ventilated atelectatic lung areas being the main reason for intrapulmonary right-to-left shunt with the consequence of severe arterial hypoxemia. The application of inhaled nitric oxide (iNO) is a therapeutic option to selectively influence pulmonary blood flow in order to improve arterial oxygenation and to decrease pulmonary artery pressure without relevant systemic side effects. Although randomized controlled trials demonstrated no survival benefit in patient populations covering the entire severity range of acute lung injury, iNO represents a feasible rescue treatment for ARDS patients with severe refractory hypoxemia and is, therefore, an important option for ARDS therapy in specialized centers.

To report on the recurrent release of charcoal from an intrapulmonary cavern in a case of acute respiratory failure after charcoal aspiration.Case report.Anaesthesiological ICU, university hospital.An 18-year-old ethanol intoxicated comatose patient regurgitated and aspirated activated charcoal during orotracheal intubation.After 2 days of mechanical ventilation, the patient was transferred to a tertiary care university hospital. On admission, acute respiratory distress syndrome with bilateral pulmonary infiltrations was diagnosed. The patient's recovery was hampered by recurrent release of charcoal from an intrapulmonary cavern. Sophisticated ventilatory support, prone positioning, secretolytics, repetitive bronchoscopy, and antibiotic therapy may have facilitated bronchoalveolar clearance and weaning after 18 days.Aspiration may be a dramatic complication if charcoal is administered in comatose patients without airway protection. In this case report, advanced intensive care measures were necessary to tackle the special feature of charcoal release from an intrapulmonary cavern.

Perioperative immunonutrition is aiming at modulating altered immunological and metabolic functions in the context of major surgery. It is defined as the supplementation of constitutionally essential substrates such as glutamine, arginine, omega-3-fatty acids or nucleotides. The application of such formula is recommended for patients undergoing major abdominal-surgical procedures and tumour surgery in the head neck area. The substitution should be given 5-7 days before and after the intervention.

The treatment of acute lung injury is one of the most challenging tasks in intensive care medicine. Conventional therapeutic options cover lung protective mechanical ventilation with low tidal volumes and adequate PEEP, restrictive fluid management, prone positioning, and early recruitment maneuvers. These options should be used in parallel and should be accompanied by a suitable anti-infective therapy. In cases of refractory hypoxemia, inhaled nitric oxide offers in most patients a successful rescue option. In specialized centers the application of ECMO remains as a final ultima ratio.

In major trauma patients, multiple organ failure (MOF) is considered a leading cause of death. Acute lung injury is deemed a "pacemaker" of MOF. The purpose of this study was to determine if incidence of organ failure and mortality in multiple trauma patients can be reduced by implementation of lung-protective strategies.All critically ill multiple trauma patients admitted to the ICU of a major trauma center in Berlin, Germany from January 1999 to December 2002 were analyzed retrospectively. Patients were ventilated pressure controlled with low tidal volumes and adequate PEEP.n=287 patients were included. The most frequent injuries were traumatic brain injury (TBI-68%), chest trauma (68%), and lung contusions (55%). Injury severity score (ISS) was 32+/-19 (mean+/-standard deviation), polytraumaschluessel (PTS) 34+/-19, and APACHE II 14+/-7. During their ICU-stay 16 patients died, 9 (56%) from TBI. Single-organ-failure occurred in n=69 patients (24%, mortality 5%), two-organ-failure in n=22 (8%, mortality 14%), and MOF in n=9 (3%, mortality 13%); one patient died from MOF 14 days after trauma. The number of days on mechanical ventilation increased depending on the number of organs failed (R=0.618, p0.001). Seven patients (2%) fulfilled ARDS criteria for longer than 24h despite optimized ventilatory settings, one died of irreversible shock. Patients with MOF had a significantly increased ICU-LOS (35+/-15 days) compared to patients without organ failure (11+/-11 days; p0.001).The low incidence of MOF in our series of trauma patients suggests that MOF may be prevented in some patients by implementation of lung-protective strategies. The improved outcome was associated with an increased ICU-LOS.

To determine whether glycemic control is less feasible when hydrocortisone is given as a bolus compared with continuous application in septic shock patients. Observational prospective pilot study. Fourteen-bed surgical university hospital ICU. Sixteen consecutive patients with septic shock receiving a continuous infusion of 200 mg hydrocortisone/day and an infusion regime of insulin keeping blood glucose below 150 mg/dl. Blood glucose and insulin infusion were adjusted to steady state before intervention. At baseline, the continuous hydrocortisone infusion was replaced with a single bolus of 50 mg hydrocortisone. During a subsequent 6-h period, blood glucose was monitored hourly and insulin infusion was kept constant. Afterwards, hydrocortisone application and adjustment of blood glucose was resumed according to standard treatment. Mean blood glucose in steady state at baseline immediately prior to intervention was 128 mg/dl (range 114–141 mg/dl; 95% confidence interval). After bolus injection of hydrocortisone, blood glucose increased significantly within 6 h with peak levels of 154 mg/dl (range 132–178 mg/dl; p

Many missions in the preclinical emergency services seem to be triggered by false indications as defined by the Federal State Rescue Act. These emergency calls are often a result of or associated with social issues. Emergency rescue personnel are confronted with social problems and as a result often feel left alone with the problem.This article promotes the understanding of emergency service personnel for the associations between social problems and health. Solution strategies for frequent social emergencies are described.This article demonstrates the associations between socioeconomic status, health and disease. Typical indications for missions in which social aspects play an important role are presented and solution strategies for the approach are suggested. A discussion is presented on how to deal with cases of child abuse and domestic violence. Three classical psychiatric problem areas with common social components are explained: psychomotor state of excitation, suicide and alcohol-associated incidents and special attention is paid to danger to third parties and aggressive patients. In addition to the treatment of medical conditions, social problems play an important role particularly for the elderly and chronically ill patients.Emergency personnel have only limited options for dealing with such problems; however, it is important to be aware of regional structures and non-medical organizations, which might be of help in such situations. These include social services, youth welfare services, crisis interventions teams and social psychiatric services.

Recommendations concerning the management of hemoglobin levels and hematocrit in patients on extracorporeal membrane oxygenation (ECMO) still advise maintenance of a normal hematocrit. In contrast, current transfusion guidelines for critically ill patients support restrictive transfusion practice. We report on a series of patients receiving venovenous ECMO (vvECMO) for acute respiratory distress syndrome (ARDS) treated according to the restrictive transfusion regimen recommended for critically ill patients. We retrospectively analyzed 18 patients receiving vvECMO due to severe ARDS. Hemoglobin concentrations were kept between 7 and 9 g/dL with a transfusion trigger at 7 g/dL or when physiological transfusion triggers were apparent. We assessed baseline data, hospital mortality, time on ECMO, hemoglobin levels, hematocrit, quantities of packed red blood cells received, and lactate concentrations and compared survivors and nonsurvivors. The overall mortality of all patients on vvECMO was 38.9%. Mean hemoglobin concentration over all patients and ECMO days was 8.30 ± 0.51 g/dL, and hematocrit was 0.25 ± 0.01, with no difference between survivors and nonsurvivors. Mean numbers of given PRBCs showed a trend towards higher quantities in the group of nonsurvivors, but the difference was not significant (1.97 ± 1.47 vs. 0.96 ± 0.76 units; P = 0.07). Mean lactate clearance from the first to the third day was 45.4 ± 28.3%, with no significant difference between survivors and nonsurvivors (P = 0.19). In our cohort of patients treated with ECMO due to severe ARDS, the application of a restrictive transfusion protocol did not result in an increased mortality. Safety and feasibility of the application of a restrictive transfusion protocol in patients on ECMO must further be evaluated in randomized controlled trials.

Critical illness polyneuropathy/myopathy (CIP/CIM) is frequently described in critically ill patients who survive severe sepsis. Clinically relevant paresis is major symptom of CIP/CIM. We aimed at determining risk factors and diagnostic value of electrophysiologic testing for CIP/CIM in patients with acute respiratory distress syndrome (ARDS).Single-center, retrospective analysis, using charts.University medical center.Fifty consecutive ARDS patients in our intensive care unit.Patient characteristics and clinical course were analyzed. All patients received early electrophysiologic testing. CIP/CIM was diagnosed by the presence of clinical relevant paresis.Clinically relevant paresis was confirmed in 27 ARDS patients (60%), whereas in 18 patients no paresis was determined (controls); five patients died before clinical assessment of paresis was feasible. Patients with paresis were older, had more days on mechanical ventilation, and had increased intensive care unit length of stay compared with controls. Patients who developed paresis had elevated daily peak blood glucose levels during 28 days of intensive care unit treatment: 166 (134, 200) mg/dL in CIP/CIM patients vs. 144 (132, 161) mg/dL in controls (median, quartiles). Twenty-five of 27 patients with paresis revealed reduced motor unit potentials, fibrillation potentials, or positive sharp waves on early electrophysiologic testing indicating CIP/CIM, whereas 16 of 18 control patients did not.In ARDS patients, paresis is a frequent complication causing prolonged mechanical ventilation and intensive care unit length of stay. An association between hyperglycemia and CIP/CIM has been found. However, since this is a retrospective survey, a causal relation is not clearly supported. In this study, the use of early electrophysiologic testing in ARDS patients was a valuable diagnostic tool for detecting CIP/CIM.

Summary Background: In this study we compare the postoperative pain relief for inguinal herniotomy in children provided by instillation of bupivacaine into the wound with that provided by a caudal block. Methods: Fifty-eight children aged 0–5 years having elective unilateral hernia repair were studied in this prospective, randomized, single-blind study. Anaesthesia was induced and maintained with oxygen, nitrous oxide, sevoflurane and propofol. Patients were randomly assigned to receive caudal analgesia with 1.0 ml·kg−1 body weight (BW) bupivacaine 0.25% or wound instillation with 0.2 ml·kg−1 BW bupivacaine 0.5% at the end of surgery. Pain was assessed over 24 h using a modified 10-point objective pain scale. During the first postoperative hour in the postanaesthesia care unit (PACU), intravenous (i.v.) piritramide (0.05 mg·kg−1) was administered to any child scoring 5 or more points on the pain scale. On the ward, rectal acetaminophen was administered by a staff nurse when considered necessary. Results: Thirty children in the caudal group and 28 children in the wound instillation group were studied. There were no statistically significant differences between the groups regarding need for i.v. opioids, discharge time from the PACU and administration of acetaminophen. No statistically significant differences in postoperative pain score were observed in 16 of a total of 17 postoperative observations. No complications and no adverse effects were observed. Conclusion: Instillation of bupivacaine into a wound provides postoperative pain relief following hernia repair, which is as effective as that provided by a postoperative caudal block.

Within the last few years, increasing evidence of relative adrenal insufficiency in septic shock evoked a reassessment of hydrocortisone therapy. To evaluate the effects of hydrocortisone on the balance between proinflammatory and antiinflammation, 40 patients with septic shock were randomized in a double-blind crossover study to receive either the first 100 mg of hydrocortisone as a loading dose and 10 mg per hour until Day 3 (n = 20) or placebo (n = 20), followed by the opposite medication until Day 6. Hydrocortisone infusion induced an increase of mean arterial pressure, systemic vascular resistance, and a decline of heart rate, cardiac index, and norepinephrine requirement. A reduction of plasma nitrite/nitrate indicated inhibition of nitric oxide formation and correlated with a reduction of vasopressor support. The inflammatory response (interleukin-6 and interleukin-8), endothelial (soluble E-selectin) and neutrophil activation (expression of CD11b, CD64), and antiinflammatory response (soluble tumor necrosis factor receptors I and II and interleukin-10) were attenuated. In peripheral blood monocytes, human leukocyte antigen-DR expression was only slightly depressed, whereas in vitro phagocytosis and the monocyte-activating cytokine interleukin-12 increased. Hydrocortisone withdrawal induced hemodynamic and immunologic rebound effects. In conclusion, hydrocortisone therapy restored hemodynamic stability and differentially modulated the immunologic response to stress in a way of antiinflammation rather than immunosuppression.

Importance Adjunctive hydrocortisone therapy is suggested by the Surviving Sepsis Campaign in refractory septic shock only. The efficacy of hydrocortisone in patients with severe sepsis without shock remains controversial. Objective To determine whether hydrocortisone therapy in patients with severe sepsis prevents the development of septic shock. Design, Setting, and Participants Double-blind, randomized clinical trial conducted from January 13, 2009, to August 27, 2013, with a follow-up of 180 days until February 23, 2014. The trial was performed in 34 intermediate or intensive care units of university and community hospitals in Germany, and it included 380 adult patients with severe sepsis who were not in septic shock. Interventions Patients were randomly allocated 1:1 either to receive a continuous infusion of 200 mg of hydrocortisone for 5 days followed by dose tapering until day 11 (n = 190) or to receive placebo (n = 190). Main Outcomes and Measures The primary outcome was development of septic shock within 14 days. Secondary outcomes were time until septic shock, mortality in the intensive care unit or hospital, survival up to 180 days, and assessment of secondary infections, weaning failure, muscle weakness, and hyperglycemia (blood glucose level >150 mg/dL [to convert to millimoles per liter, multiply by 0.0555]). Results The intention-to-treat population consisted of 353 patients (64.9% male; mean [SD] age, 65.0 [14.4] years). Septic shock occurred in 36 of 170 patients (21.2%) in the hydrocortisone group and 39 of 170 patients (22.9%) in the placebo group (difference, −1.8%; 95% CI, −10.7% to 7.2%; P = .70). No significant differences were observed between the hydrocortisone and placebo groups for time until septic shock; mortality in the intensive care unit or in the hospital; or mortality at 28 days (15 of 171 patients [8.8%] vs 14 of 170 patients [8.2%], respectively; difference, 0.5%; 95% CI, −5.6% to 6.7%; P = .86), 90 days (34 of 171 patients [19.9%] vs 28 of 168 patients [16.7%]; difference, 3.2%; 95% CI, −5.1% to 11.4%; P = .44), and 180 days (45 of 168 patients [26.8%] vs 37 of 167 patients [22.2%], respectively; difference, 4.6%; 95% CI, −4.6% to 13.7%; P = .32). In the hydrocortisone vs placebo groups, 21.5% vs 16.9% had secondary infections, 8.6% vs 8.5% had weaning failure, 30.7% vs 23.8% had muscle weakness, and 90.9% vs 81.5% had hyperglycemia. Conclusions and Relevance Among adults with severe sepsis not in septic shock, use of hydrocortisone compared with placebo did not reduce the risk of septic shock within 14 days. These findings do not support the use of hydrocortisone in these patients. Trial Registration clinicaltrials.gov Identifier:NCT00670254