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Kruse M, Liesenborghs KE, Josuttis D, Plettig P, Guembel D, Lenz IK, Guethoff C, Gebhardt V, Schmittner MD. Early Autocalibrated Arterial Waveform Analysis for the Management of Burn Shock-A Cohort Study. J Intensive Care Med 2024; 39:655-664. [PMID: 38173245 DOI: 10.1177/08850666231224388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
Adequate fluid therapy is crucial for resuscitation after major burns. To adapt this to individual patient demands, standard is adjustment of volume to laboratory parameters and values of enhanced hemodynamic monitoring. To implement calibrated parameters, patients must have reached the intensive care unit (ICU). The aim of this study was, to evaluate the use of an auto-calibrated enhanced hemodynamic monitoring device to improve fluid management before admission to ICU. We used PulsioflexProAqt® (Getinge) during initial treatment and burn shock resuscitation. Analysis was performed regarding time of measurement, volume management, organ dysfunction, and mortality. We conducted a monocentre, prospective cohort study of 20 severely burned patients, >20% total body surface area (TBSA), receiving monitoring immediately after admission. We compared to 57 patients, matched in terms of TBSA, age, sex, and existence of inhalation injury out of a retrospective control group, who received standard care. Hemodynamic measurement with autocalibrated monitoring started significantly earlier: 3.75(2.67-6.0) hours (h) after trauma in the study group versus 13.6(8.1-17.5) h in the control group (P < .001). Study group received less fluid after 6 h: 1.7(1.2-2.2) versus 2.3(1.6-2.8) ml/TBSA%/kg, P = .043 and 12 h: 3.0(2.5-4.0) versus 4.2(3.1-5.0) ml/TBSA%/kg, P = .047. Dosage of norepinephrine was higher after 18 h in the study group: 0.20(0.12-0.3) versus 0.08(0.02-0.18) µg/kg/min, P = .014. The study group showed no adult respiratory distress syndrome versus 21% in the control group, P = .031. There was no difference in other organ failures, organ replacement therapy, and mortality. The use of auto-calibrated enhanced hemodynamic monitoring is a fast and feasible way to guide early fluid therapy after burn trauma. It reduces the time to reach information about patient's volume capacity. Management of fluid application changed to a more restrictive fluid use in the early period of burn shock and led to a reduction of pulmonary complications.
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Affiliation(s)
- Marianne Kruse
- Department of Anesthesiology, Intensive Care and Pain Medicine, BG Klinikum Unfallkrankenhaus Berlin, Berlin, DE, Germany
| | - Konrad Ernst Liesenborghs
- Department of Anesthesiology, Intensive Care and Pain Medicine, BG Klinikum Unfallkrankenhaus Berlin, Berlin, DE, Germany
| | - David Josuttis
- Department of Anesthesiology, Intensive Care and Pain Medicine, BG Klinikum Unfallkrankenhaus Berlin, Berlin, DE, Germany
| | - Philip Plettig
- Department of Anesthesiology, Intensive Care and Pain Medicine, BG Klinikum Unfallkrankenhaus Berlin, Berlin, DE, Germany
| | - Denis Guembel
- Department of Trauma and Orthopaedic Surgery, BG Klinikum Unfallkrankenhaus Berlin, Berlin, DE, Germany
- Department of Trauma, Reconstructive Surgery and Rehabilitation Medicine, University Medicine Greifswald, Greifswald, DE, Germany
| | - Ida Katinka Lenz
- Department of Anesthesiology, Intensive Care and Pain Medicine, BG Klinikum Unfallkrankenhaus Berlin, Berlin, DE, Germany
| | - Claas Guethoff
- Centre for Clinical Research, Biostatistics, BG Klinikum Unfallkrankenhaus Berlin, Berlin, DE, Germany
| | - Volker Gebhardt
- Department of Anesthesiology, Intensive Care and Pain Medicine, BG Klinikum Unfallkrankenhaus Berlin, Berlin, DE, Germany
| | - Marc Dominik Schmittner
- Department of Anesthesiology, Intensive Care and Pain Medicine, BG Klinikum Unfallkrankenhaus Berlin, Berlin, DE, Germany
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Sensen B, Nierhaus A, Kluge S. [Corticosteroids in intensive care medicine]. Dtsch Med Wochenschr 2024; 149:714-718. [PMID: 38781995 DOI: 10.1055/a-2128-5319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
In the case of septic shock, recent studies show benefits from a combination of hydrocortisone and fludrocortisone, but clear guideline recommendations are still lacking. For severe community-acquired pneumonia, early corticosteroid therapy is recommended. Corticosteroid therapy should not be used in influenza-associated community-acquired pneumonia. In contrast, a significantly lower 28-day mortality rate was observed for COVID-19 by the use of dexamethasone. Current guidelines also recommend the use of corticosteroids in Acute Respiratory Distress Syndrome. These recommendations are based primarily on studies that started steroid therapy early. However, many questions such as the type of corticosteroid, the timing and duration of therapy, and the dosage still remain unanswered.
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Affiliation(s)
- Barbara Sensen
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Axel Nierhaus
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Stefan Kluge
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
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Busch HJ, Wolfrum S, Michels G, Baumgärtel M, Bodmann KF, Buerke M, Burst V, Enghard P, Ertl G, Fach WA, Hanses F, Heppner HJ, Hermes C, Janssens U, John S, Jung C, Karagiannidis C, Kiehl M, Kluge S, Koch A, Kochanek M, Korsten P, Lepper PM, Merkel M, Müller-Werdan U, Neukirchen M, Pfeil A, Riessen R, Rottbauer W, Schellong S, Scherg A, Sedding D, Singler K, Thieme M, Trautwein C, Willam C, Werdan K. [Clinical acute and emergency medicine curriculum-focus on internal medicine : Recommendations for advanced training in internal medicine in the emergency department]. Med Klin Intensivmed Notfmed 2024; 119:1-50. [PMID: 38625382 PMCID: PMC11098871 DOI: 10.1007/s00063-024-01113-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/31/2024] [Indexed: 04/17/2024]
Abstract
In Germany, physicians qualify for emergency medicine by combining a specialty medical training-e.g. internal medicine-with advanced training in emergency medicine according to the statutes of the State Chambers of Physicians largely based upon the Guideline Regulations on Specialty Training of the German Medical Association. Internal medicine and their associated subspecialities represent an important column of emergency medicine. For the internal medicine aspects of emergency medicine, this curriculum presents an overview of knowledge, skills (competence levels I-III) as well as behaviours and attitudes allowing for the best treatment of patients. These include general aspects (structure and process quality, primary diagnostics and therapy as well as indication for subsequent treatment; resuscitation room management; diagnostics and monitoring; general therapeutic measures; hygiene measures; and pharmacotherapy) and also specific aspects concerning angiology, endocrinology, diabetology and metabolism, gastroenterology, geriatric medicine, hematology and oncology, infectiology, cardiology, nephrology, palliative care, pneumology, rheumatology and toxicology. Publications focussing on contents of advanced training are quoted in order to support this concept. The curriculum has primarily been written for internists for their advanced emergency training, but it may generally show practising emergency physicians the broad spectrum of internal medicine diseases or comorbidities presented by patients attending the emergency department.
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Affiliation(s)
- Hans-Jörg Busch
- Zentrum für Notfall- und Rettungsmedizin, Universitäts-Notfallzentrum Freiburg, Universitätsklinikum Freiburg, Freiburg, Deutschland
| | - Sebastian Wolfrum
- Interdisziplinäre Notaufnahme Campus Lübeck, Universitätsklinikum Schleswig-Holstein, Lübeck, Deutschland
| | - Guido Michels
- Notfallzentrum, Krankenhaus der Barmherzigen Brüder Trier, Medizincampus der Universitätsmedizin Mainz, Trier, Deutschland
| | - Matthias Baumgärtel
- Klinikum Nürnberg, Universitätsklinik für Innere Medizin 3 der Paracelsus Medizinischen Privatuniversität, Nürnberg, Deutschland
| | | | - Michael Buerke
- Medizinische Klinik II, St. Marien-Krankenhaus Siegen, Siegen, Deutschland
| | - Volker Burst
- Schwerpunkt Klinische Akut- und Notfallmedizin und Klinik II für Innere Medizin, Uniklinik Köln, Köln, Deutschland
| | - Philipp Enghard
- Klinik mit Schwerpunkt Nephrologie und Internistische Intensivmedizin, Charité Universitätsmedizin, Berlin, Deutschland
| | - Georg Ertl
- Deutsches Zentrum für Herzinsuffizienz, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - Wolf Andreas Fach
- MVZ CCB am AGAPLESION Bethanien Krankenhaus, Frankfurt (Main), Deutschland
| | - Frank Hanses
- Interdisziplinäre Notaufnahme, Universitätsklinikum Regensburg, Regensburg, Deutschland
| | - Hans Jürgen Heppner
- Klinik für Geriatrie und Geriatrische Tagesklinik, Klinikum Bayreuth - Medizincampus Oberfranken und Friedrich-Alexander-Universität Erlangen-Nürnberg, Bayreuth, Deutschland
| | | | - Uwe Janssens
- Klinik für Innere Medizin und Internistische Intensivmedizin, St-Antonius-Hospital gGmbH, Eschweiler, Deutschland
| | - Stefan John
- Medizinische Klinik 8, Abteilung für Internistische Intensivmedizin, Klinikum Nürnberg-Süd, Paracelsus Medizinische Privatuniversität, Nürnberg, Deutschland
| | - Christian Jung
- Klinik für Kardiologie, Pneumologie und Angiologie des Universitätsklinikums Düsseldorf, Heinrich-Heine Universität Düsseldorf, Düsseldorf, Deutschland
| | - Christian Karagiannidis
- ARDS und ECMO Zentrum Köln-Merheim, Kliniken Köln und Universität Witten/Herdecke, Köln, Deutschland
| | - Michael Kiehl
- Medizinische Klinik I, Klinikum Frankfurt (Oder), Frankfurt (Oder), Deutschland
| | - Stefan Kluge
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Alexander Koch
- Medizinische Klinik III, Universitätsklinikum Aachen, Aachen, Deutschland
| | | | - Peter Korsten
- Klinik für Rheumatologie und Klinische Immunologie, St. Josef-Stift Sendenhorst, Sendenhorst, Deutschland
| | - Philipp M Lepper
- Klinik für Akut- und Notfallmedizin, Universität und Universitätsklinikum des Saarlandes, Homburg, Deutschland
| | | | - Ursula Müller-Werdan
- Medizinische Klinik für Geriatrie und Altersmedizin, der Charité - Universitätsmedizin Berlin und EGZB, Berlin, Deutschland
| | - Martin Neukirchen
- Interdisziplinäres Zentrum für Palliativmedizin und Klinik für Anästhesiologie, Universitätsklinikum Düsseldorf, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Deutschland
| | - Alexander Pfeil
- Klinik für Innere Medizin III, Universitätsklinikum Jena, Jena, Deutschland
| | - Reimer Riessen
- Internistische Intensivstation 93, Dept. f. Innere Medizin, Universitätsklinikum Tübingen, Tübingen, Deutschland
| | - Wolfgang Rottbauer
- Klinik für Innere Medizin II (Kardiologie, Angiologie, Pneumologie, Intensivmedizin, Sport- und Rehabilitationsmedizin), Universitätsklinikum Ulm, Ulm, Deutschland
| | | | | | - Daniel Sedding
- Universitätsklinik und Poliklinik für Innere Medizin III, Universitätsklinikum Halle (Saale), Ernst-Grube-Straße 40, 06097, Halle (Saale), Deutschland
| | - Katrin Singler
- Universitätsklinik für Innere Medizin - Geriatrie & Institut für Biomedizin des Alterns, Klinikum Nürnberg Paracelsus Medizinische Privatuniversität & Friedrich-Alexander Universität Erlangen-Nürnberg, Nürnberg & Erlangen, Deutschland
| | - Marcus Thieme
- Abteilung Innere Medizin und REGIOMED Gefäßzentrum, REGIOMED Klinikum Sonneberg, Sonneberg und Klinik für Innere Medizin I, Universitätsklinikum Jena, Jena, Deutschland
| | | | - Carsten Willam
- Medizinische Klinik 4, Universitätsklinikum Erlangen, Erlangen, Deutschland
| | - Karl Werdan
- Universitätsklinik und Poliklinik für Innere Medizin III, Universitätsklinikum Halle (Saale), Ernst-Grube-Straße 40, 06097, Halle (Saale), Deutschland.
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Schmoch T, Weigand MA, Brenner T. [Guideline-conform treatment of sepsis]. DIE ANAESTHESIOLOGIE 2024; 73:4-16. [PMID: 37950017 DOI: 10.1007/s00101-023-01354-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/02/2023] [Indexed: 11/12/2023]
Abstract
The time to administration of broad-spectrum antibiotics and (secondarily) to the initiation of hemodynamic stabilization are the most important factors influencing survival of patients with sepsis and septic shock; however, the basic prerequisite for the initiation of an adequate treatment is that a suspected diagnosis of sepsis is made first. Therefore, the treatment of sepsis, even before it has begun, is an interdisciplinary and interprofessional task. This article provides an overview of the current state of the art in sepsis treatment and points towards new evidence that has the potential to change guideline recommendations in the coming years. In summary, the following points are critical: (1) sepsis must be diagnosed as soon as possible and the implementation of a source control intervention (in case of a controllable source) has to be implemented as soon as (logistically) possible. (2) In general, intravenous broad-spectrum antibiotics should be given within the first hour after diagnosis if sepsis or septic shock is suspected. In organ dysfunction without shock, where sepsis is a possible but unlikely cause, the results of focused advanced diagnostics should be awaited before a decision to give broad-spectrum antibiotics is made. If it is not clear within 3 h whether sepsis is the cause, broad-spectrum antibiotics should be given when in doubt. Administer beta-lactam antibiotics as a prolonged (or if therapeutic drug monitoring is available, continuous) infusion after an initial loading dose. (3) Combination treatment with two agents for one pathogen group should remain the exception (e.g. multidrug-resistant gram-negative pathogens). (4) In the case of doubt, the duration of anti-infective treatment should rather be shorter than longer. Procalcitonin can support the clinical decision to stop (not to start!) antibiotic treatment! (5) For fluid treatment, if hypoperfusion is present, the first (approximately) 2L (30 ml/kg BW) of crystalloid solution is usually safe and indicated. After that, the rule is: less is more! Any further fluid administration should be carefully weighed up with the help of dynamic parameters, the patient's clinical condition and echo(cardio)graphy.
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Affiliation(s)
- Thomas Schmoch
- Klinik für Anästhesiologie und Intensivmedizin, Hôpitaux Robert Schuman, Hôpital Kirchberg, 9 , rue Edward Steichen, 2540, Luxemburg, Luxemburg.
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Essen, Universität Duisburg-Essen, Essen, Deutschland.
| | - Markus A Weigand
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - Thorsten Brenner
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Essen, Universität Duisburg-Essen, Essen, Deutschland
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5
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Greppmair S, Liebchen U. [Treatment of sepsis on the pulse of time : Proven standards and current trends]. DIE ANAESTHESIOLOGIE 2024; 73:1-3. [PMID: 38226994 DOI: 10.1007/s00101-023-01366-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/20/2023] [Indexed: 01/17/2024]
Affiliation(s)
- Sebastian Greppmair
- Klinik für Anaesthesiologie, LMU Klinikum, LMU München, Marchioninistr. 15, 81377, München, Deutschland
| | - Uwe Liebchen
- Klinik für Anaesthesiologie, LMU Klinikum, LMU München, Marchioninistr. 15, 81377, München, Deutschland.
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Gräfe C, Weidhase L, Liebchen U, Weigand MA, Scharf C. [Hemoperfusion in anesthesia and intensive care medicine: benefits, risks, and evidence for different systems]. DIE ANAESTHESIOLOGIE 2023; 72:843-851. [PMID: 37707564 DOI: 10.1007/s00101-023-01341-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/14/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND Hemoperfusion is a technique for the extracorporeal elimination of endogenous and exogenous toxins and harmful mediators by adsorption. It can be used as a stand-alone device, as part of a heart-lung machine or extracorporeal membrane oxygenation (ECMO) or, as is currently the case, integrated into a kidney replacement procedure. In the meantime, various suppliers offer devices with different technologies. OBJECTIVE The aim of this work was to evaluate the benefits, risks and evidence of the different systems, how they work and for which indications they are approved in Germany. METHOD To achieve this goal, a narrative assessment of the existing literature and guidelines for different indications was performed. The focus was on in vivo studies. RESULTS In principle, a distinction must be made in adsorption techniques between pure adsorption and the combination as adsorption and kidney replacement therapy. The adsorbers available in Germany include Cytosorb®, HA-330, Seraph®-100 and Toraymyxin. Combined procedures (adsorption and kidney replacement) are offered with coupled plasma filtration and adsorption (CPFA) and oXiris®. Most adsorbers have been developed for cytokine and endotoxin removal in patients with sepsis; however, to date, no randomized controlled trial (RCT) has demonstrated a survival benefit when using hemoperfusion. Therefore, the S3 guidelines for treatment of sepsis and the surviving sepsis campaign guidelines advise against its routine use. When the corona pandemic began, hemoperfusion was considered as a promising therapeutic approach. Cytosorb®, Seraph®-100, and oXiris® received emergency approval by the FDA to be used in critically ill patients with COVID-19, so questions arose about the appropriateness and importance of its use; however, the data generated did not show positive results, so its use cannot be recommended routinely either. In addition, they are not mentioned as a treatment option in the current guidelines. The use of adsorption procedures in patients with liver failure and rhabdomyolysis has only been rudimentarily studied, so any evidence is currently lacking. The only adsorber that has CE approval in Germany for both applications is Cytosorb®. In the next few years, studies will have to follow that investigate the efficacy and thus either justify or refute the use in clinical routine. Hemoperfusion procedures are used in the heart-lung machine as part of cardiac surgery for either cytokine or anticoagulant adsorption. No congruent data are available to support the use for the elimination of cytokines. If emergency cardiac surgery is required in a patient with pre-existing anticoagulation, hemoperfusion procedures can be used to prevent bleeding complications. Cytosorb® has CE approval for this indication. All available techniques are nonselective adsorption processes, so that adsorption of known and unknown substances can occur. Unintentional adsorption of drugs, such as various anti-infective agents is a relevant risk, especially when used in patients with sepsis. DISCUSSION Various adsorption systems can eliminate different known and unknown substances. Currently, there is a lack of evidence for all indications and systems to justify their routine use except in clinical trials. Future clinical trials should evaluate the potential benefits but also dangers, so that in the meantime the routine use can be justified or a recommendation against the use can be given.
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Affiliation(s)
- Caroline Gräfe
- Klinik für Anaesthesiologie, LMU Klinikum München, Marchioninistr. 15, 81377, München, Deutschland
| | - Lorenz Weidhase
- Interdisziplinäre internistische Intensivmedizin, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Uwe Liebchen
- Klinik für Anaesthesiologie, LMU Klinikum München, Marchioninistr. 15, 81377, München, Deutschland
| | - Markus A Weigand
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - Christina Scharf
- Klinik für Anaesthesiologie, LMU Klinikum München, Marchioninistr. 15, 81377, München, Deutschland.
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Yang X, Zeng J, Yu X, Wang Z, Wang D, Zhou Q, Bai T, Xu Y. PCT, IL-6, and IL-10 facilitate early diagnosis and pathogen classifications in bloodstream infection. Ann Clin Microbiol Antimicrob 2023; 22:103. [PMID: 37986183 PMCID: PMC10662675 DOI: 10.1186/s12941-023-00653-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 11/05/2023] [Indexed: 11/22/2023] Open
Abstract
BACKGROUND In the diagnosis of bloodstream infection (BSI), various inflammatory markers such as C-reactive protein (CRP), procalcitonin (PCT), interleukins (IL), white blood cell count (WBC), neutrophil percentage (NE%), platelet count (PLT), and erythrocyte sedimentation rate (ESR) have been extensively utilized. However, their specific roles in distinguishing BSI from local bacterial infection (LBI) and in classifying BSI pathogens remain uncertain. METHODS A historical cohort study was conducted, involving the enrollment of 505 patients with BSI and 102 patients with LBI. To validate the reliability of the clinical data obtained from this cohort, mouse models of BSI were utilized. RESULTS Our findings revealed that patients with BSI had significantly higher levels of inflammatory markers, including CRP, PCT, IL-6, IL-10, WBC, NE%, and ESR, compared to those with LBI (p < 0.05). The receiver operating characteristic (ROC) curve analysis demonstrated that CRP, PCT, IL-6, IL-10, ESR and NE% exhibited excellent diagnostic efficacy for BSI. Additionally, we observed significant differences in CRP, PCT, IL-6, and IL-10 levels between patients with BSI caused by Gram-positive bacteria (GP-BSI) and Gram-negative bacteria (GN-BSI), but no significant variations were found among specific bacterial species. Furthermore, our study also found that CRP, PCT, and IL-10 have good discriminatory ability for vancomycin-resistant Enterococcus (VRE), but they show no significant diagnostic efficacy for other multidrug-resistant organisms (MDROs) such as carbapenem-resistant Enterobacteriaceae (CRE), carbapenem-resistant Pseudomonas aeruginosa (CRPA), and methicillin-resistant Staphylococcus aureus (MRSA). In our mouse model experiments, we observed a remarkable increase in PCT, IL-6, and IL-10 levels in mice with GN-BSI compared to those with GP-BSI. CONCLUSION Our study has confirmed that PCT, IL-6, and IL-10 are efficient biomarkers for distinguishing between BSI and LBI. Furthermore, they can be utilized to classify BSI pathogens and differentiate between VRE and vancomycin-susceptible Enterococcus. These findings are extremely valuable for clinicians as they enable timely initiation of empiric antibiotic therapies and ultimately lead to improved clinical outcomes for patients with BSI.
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Affiliation(s)
- Xianggui Yang
- Department of Laboratory Medicine, Clinical Medical College and the First Affiliated Hospital of Chengdu Medical College, Chengdu, Sichuan, China.
| | - Jun Zeng
- Division of Pulmonary and Critical Care Medicine, Clinical Medical College and the First Affiliated Hospital of Chengdu Medical College, Chengdu, Sichuan, China
| | - Xuejing Yu
- Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Zhenguo Wang
- Department of Stomatology, Clinical Medical College and the First Affiliated Hospital of Chengdu Medical College, Chengdu, Sichuan, China
| | - Dan Wang
- Department of Laboratory Medicine, Clinical Medical College and the First Affiliated Hospital of Chengdu Medical College, Chengdu, Sichuan, China
| | - Qin Zhou
- Department of Laboratory Medicine, Clinical Medical College and the First Affiliated Hospital of Chengdu Medical College, Chengdu, Sichuan, China
| | - Tingting Bai
- Department of Laboratory Medicine, Clinical Medical College and the First Affiliated Hospital of Chengdu Medical College, Chengdu, Sichuan, China
| | - Ying Xu
- Department of Laboratory Medicine, Clinical Medical College and the First Affiliated Hospital of Chengdu Medical College, Chengdu, Sichuan, China.
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Kühn A, Gründling M. [Preclinical early detection and diagnosis of sepsis - step by step]. Dtsch Med Wochenschr 2023; 148:1201-1205. [PMID: 37657458 DOI: 10.1055/a-2127-6035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/03/2023]
Abstract
Because of very unspecific sepsis symptoms, early recognition of the emergency sepsis is difficult. If the disease is recognized in time it is possible to initiate diagnosis and treatment quickly. Rapid treatment of sepsis leads to lower mortality and less severe long-term consequences. Early detection is therefore of central importance in the diagnostic and therapeutic process, also in the outpatient setting.
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Böcklein M, Beck M, Shmygalev S. [Distributive shock]. DIE ANAESTHESIOLOGIE 2023:10.1007/s00101-023-01304-1. [PMID: 37493826 DOI: 10.1007/s00101-023-01304-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Accepted: 05/23/2023] [Indexed: 07/27/2023]
Abstract
In shock there is a significant mismatch between oxygen supply and consumption. In recent years the classification of forms of shock has been established based on pathophysiological and clinical aspects. The term distributive shock includes septic, anaphylactic and neurogenic shock. All these forms share a distinct vasoplegia with a relative volume deficiency. The adequate treatment of patients with distributive shock includes a rapid diagnosis and a consistent emergency treatment consisting of volume and catecholamine administration as well as additional specific emergency procedures when necessary.
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Affiliation(s)
- M Böcklein
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Augsburg, Augsburg, Deutschland.
| | - M Beck
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Augsburg, Augsburg, Deutschland
| | - S Shmygalev
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Augsburg, Augsburg, Deutschland
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10
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Kumpf O, Assenheimer M, Bloos F, Brauchle M, Braun JP, Brinkmann A, Czorlich P, Dame C, Dubb R, Gahn G, Greim CA, Gruber B, Habermehl H, Herting E, Kaltwasser A, Krotsetis S, Kruger B, Markewitz A, Marx G, Muhl E, Nydahl P, Pelz S, Sasse M, Schaller SJ, Schäfer A, Schürholz T, Ufelmann M, Waydhas C, Weimann J, Wildenauer R, Wöbker G, Wrigge H, Riessen R. Quality indicators in intensive care medicine for Germany - fourth edition 2022. GERMAN MEDICAL SCIENCE : GMS E-JOURNAL 2023; 21:Doc10. [PMID: 37426886 PMCID: PMC10326525 DOI: 10.3205/000324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Indexed: 07/11/2023]
Abstract
The measurement of quality indicators supports quality improvement initiatives. The German Interdisciplinary Society of Intensive Care Medicine (DIVI) has published quality indicators for intensive care medicine for the fourth time now. After a scheduled evaluation after three years, changes in several indicators were made. Other indicators were not changed or only minimally. The focus remained strongly on relevant treatment processes like management of analgesia and sedation, mechanical ventilation and weaning, and infections in the ICU. Another focus was communication inside the ICU. The number of 10 indicators remained the same. The development method was more structured and transparency was increased by adding new features like evidence levels or author contribution and potential conflicts of interest. These quality indicators should be used in the peer review in intensive care, a method endorsed by the DIVI. Other forms of measurement and evaluation are also reasonable, for example in quality management. This fourth edition of the quality indicators will be updated in the future to reflect the recently published recommendations on the structure of intensive care units by the DIVI.
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Affiliation(s)
- Oliver Kumpf
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Anesthesiology and Intensive Care Medicine, Berlin, Germany
| | | | - Frank Bloos
- Jena University Hospital, Department of Anaesthesiology and Intensive Care Medicine, Jena, Germany
| | - Maria Brauchle
- Landeskrankenhaus Feldkirch, Department of Anesthesiology and Intensive Care Medicine, Feldkirch, Austria
| | - Jan-Peter Braun
- Martin-Luther-Krankenhaus, Department of Anesthesiology and Intensive Care Medicine, Berlin, Germany
| | - Alexander Brinkmann
- Klinikum Heidenheim, Department of Anesthesia, Surgical Intensive Care Medicine and Special Pain Therapy, Heidenheim, Germany
| | - Patrick Czorlich
- University Medical Center Hamburg-Eppendorf, Department of Neurosurgery, Hamburg, Germany
| | - Christof Dame
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neonatology, Berlin, Germany
| | - Rolf Dubb
- Kreiskliniken Reutlingen, Academy of the District Hospitals Reutlingen, Germany
| | - Georg Gahn
- Städt. Klinikum Karlsruhe gGmbH, Department of Neurology, Karlsruhe, Germany
| | - Clemens-A. Greim
- Klinikum Fulda, Department of Anesthesia and Surgical Intensive Care Medicine, Fulda, Germany
| | - Bernd Gruber
- Niels Stensen Clinics, Marienhospital Osnabrueck, Department Hospital Hygiene, Osnabrueck, Germany
| | - Hilmar Habermehl
- Kreiskliniken Reutlingen, Klinikum am Steinenberg, Center for Intensive Care Medicine, Reutlingen, Germany
| | - Egbert Herting
- Universitätsklinikum Schleswig-Holstein, Department of Pediatrics and Adolescent Medicine, Campus Lübeck, Germany
| | - Arnold Kaltwasser
- Kreiskliniken Reutlingen, Academy of the District Hospitals Reutlingen, Germany
| | - Sabine Krotsetis
- Universitätsklinikum Schleswig-Holstein, Nursing Development and Nursing Science, affiliated with the Nursing Directorate Campus Lübeck, Germany
| | - Bastian Kruger
- Klinikum Heidenheim, Department of Anesthesia, Surgical Intensive Care Medicine and Special Pain Therapy, Heidenheim, Germany
| | | | - Gernot Marx
- University Hospital RWTH Aachen, Department of Intensive Care Medicine and Intermediate Care, Aachen, Germany
| | | | - Peter Nydahl
- Universitätsklinikum Schleswig-Holstein, Nursing Development and Nursing Science, affiliated with the Nursing Directorate Campus Kiel, Germany
| | - Sabrina Pelz
- Universitäts- und Rehabilitationskliniken Ulm, Intensive Care Unit, Ulm, Germany
| | - Michael Sasse
- Medizinische Hochschule Hannover, Department of Pediatric Cardiology and Pediatric Intensive Care Medicine, Hanover, Germany
| | - Stefan J. Schaller
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Anesthesiology and Intensive Care Medicine, Berlin, Germany
- Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Department of Anesthesiology and Intensive Care Medicine, Munich, Germany
| | | | - Tobias Schürholz
- University Hospital RWTH Aachen, Department of Intensive Care Medicine and Intermediate Care, Aachen, Germany
| | - Marina Ufelmann
- Technical University of Munich, Klinikum rechts der Isar, Department of Nursing, Munich, Germany
| | - Christian Waydhas
- Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil, Surgical University Hospital and Polyclinic, Bochum, Germany
- Medical Department of the University of Duisburg-Essen, Essen, Germany
| | - Jörg Weimann
- Sankt-Gertrauden Krankenhaus, Department of Anesthesia and Interdisciplinary Intensive Care Medicine, Berlin, Germany
| | | | - Gabriele Wöbker
- Helios Universitätsklinikum Wuppertal, Universität Witten-Herdecke, Department of Intensive Care Medicine, Wuppertal, Germany
| | - Hermann Wrigge
- Bergmannstrost Hospital Halle, Department of Anesthesiology, Intensive Care and Emergency Medicine, Pain Therapy, Halle, Germany
- Martin-Luther University Halle-Wittenberg, Medical Faculty, Halle, Germany
| | - Reimer Riessen
- Universitätsklinikum Tübingen, Department of Internal Medicine, Medical Intensive Care Unit, Tübingen, Germany
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11
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Putko K, Erber J, Wagner F, Busch D, Schuster H, Schmid RM, Lahmer T, Rasch S. Accuracy of hemodynamic parameters derived by GE E-PiCCO in comparison with PiCCO® in patients admitted to the intensive care unit. Sci Rep 2023; 13:6861. [PMID: 37100865 PMCID: PMC10133386 DOI: 10.1038/s41598-023-34141-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 04/25/2023] [Indexed: 04/28/2023] Open
Abstract
To evaluate the agreement and accuracy of a novel advanced hemodynamic monitoring (AHM) device, the GE E-PiCCO module, with the well-established PiCCO® device in intensive care patients using pulse contour analysis (PCA) and transpulmonary thermodilution (TPTD). A total of 108 measurements were performed in 15 patients with AHM. Each of the 27 measurement sequences (one to four per patient) consisted of a femoral and a jugular indicator injection via central venous catheters (CVC) and measurement using both PiCCO (PiCCO® Jug and Fem) and GE E-PiCCO (GE E-PiCCO Jug and Fem) devices. For statistical analysis, Bland-Altman plots were used to compare the estimated values derived from both devices. The cardiac index measured via PCA (CIpc) and TPTD (CItd) was the only parameter that fulfilled all a priori-defined criteria based on bias and the limits of agreement (LoA) by the Bland-Altman method as well as the percentage error by Critchley and Critchley for all three comparison pairs (GE E-PiCCO Jug vs. PiCCO® Jug, GE E-PiCCO Fem vs. PiCCO® Fem, and GE E-PiCCO Fem vs. GE E-PiCCO Jug), while the GE E-PiCCO did not accurately estimate EVLWI, SVRI, SVV, and PPV values measured via the jugular and femoral CVC compared with values assessed by PiCCO®. Consequently, measurement discrepancy should be considered on evaluation and interpretation of the hemodynamic status of patients admitted to the ICU when using the GE E-PiCCO module instead of the PiCCO® device.
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Affiliation(s)
- Katarzyna Putko
- Department of Internal Medicine II, School of Medicine, University Hospital rechts der Isar, Technical University of Munich, Munich, Germany
| | - Johanna Erber
- Department of Internal Medicine II, School of Medicine, University Hospital rechts der Isar, Technical University of Munich, Munich, Germany
| | - Franziska Wagner
- Department of Internal Medicine II, School of Medicine, University Hospital rechts der Isar, Technical University of Munich, Munich, Germany
| | - Daniel Busch
- Department of Internal Medicine II, School of Medicine, University Hospital rechts der Isar, Technical University of Munich, Munich, Germany
| | - Hannah Schuster
- Department of Internal Medicine II, School of Medicine, University Hospital rechts der Isar, Technical University of Munich, Munich, Germany
| | - Roland M Schmid
- Department of Internal Medicine II, School of Medicine, University Hospital rechts der Isar, Technical University of Munich, Munich, Germany
| | - Tobias Lahmer
- Department of Internal Medicine II, School of Medicine, University Hospital rechts der Isar, Technical University of Munich, Munich, Germany
| | - Sebastian Rasch
- Department of Internal Medicine II, School of Medicine, University Hospital rechts der Isar, Technical University of Munich, Munich, Germany.
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Tober R, Schnetzke U, Fleischmann M, Yomade O, Schrenk K, Hammersen J, Glaser A, Thiede C, Hochhaus A, Scholl S. Impact of treatment intensity on infectious complications in patients with acute myeloid leukemia. J Cancer Res Clin Oncol 2023; 149:1569-1583. [PMID: 35583829 PMCID: PMC10020242 DOI: 10.1007/s00432-022-03995-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 03/23/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Infectious complications reflect a major challenge in the treatment of patients with acute myeloid leukemia (AML). Both induction chemotherapy and epigenetic treatment with hypomethylating agents (HMA) are associated with severe infections, while neutropenia represents a common risk factor. Here, 220 consecutive and newly diagnosed AML patients were analyzed with respect to infectious complications dependent on treatment intensity and antifungal prophylaxis applied to these patients. PATIENTS AND METHODS We retrospectively analyzed 220 patients with newly diagnosed AML at a tertiary care hospital between August 2016 and December 2020. The median age of AML patients undergoing induction chemotherapy (n = 102) was 61 years (25-76 years). Patients receiving palliative AML treatment (n = 118) had a median age of 75 years (53-91 years). We assessed the occurrence of infectious complication including the classification of pulmonary invasive fungal disease (IFD) according to the EORTC/MSG criteria at diagnosis and until day 100 after initiation of AML treatment. Furthermore, admission to intensive care unit (ICU) and subsequent outcome was analyzed for both groups of AML patients, respectively. RESULTS AML patients subsequently allocated to palliative AML treatment have a significantly higher risk of pneumonia at diagnosis compared to patients undergoing induction chemotherapy (37.3% vs. 13.7%, P < 0.001) including a higher probability of atypical pneumonia (22.0% vs. 10.8%, P = 0.026). Furthermore, urinary tract infections are more frequent in the palliative subgroup at the time of AML diagnosis (5.1% vs. 0%, P = 0.021). Surprisingly, the incidence of pulmonary IFD is significantly lower after initiation of palliative AML treatment compared to the occurrence after induction chemotherapy (8.4% vs. 33.3%, P < 0.001) despite only few patients of the palliative treatment group received Aspergillus spp.-directed antifungal prophylaxis. The overall risk for infectious complications at AML diagnosis is significantly higher for palliative AML patients at diagnosis while patients undergoing induction chemotherapy have a significantly higher risk of infections after initiation of AML treatment. In addition, there is a strong correlation between the occurrence of pneumonia including atypical pneumonia and pulmonary IFD and the ECOG performance status at diagnosis in the palliative AML patient group. Analysis of intensive care unit (ICU) treatment (e.g. in case of sepsis or pneumonia) for both subgroups reveals a positive outcome in 10 of 15 patients (66.7%) with palliative AML treatment and in 15 of 18 patients (83.3%) receiving induction chemotherapy. Importantly, the presence of infections and the ECOG performance status at diagnosis significantly correlate with the overall survival (OS) of palliative AML patients (315 days w/o infection vs. 69 days with infection, P 0.0049 and 353 days for ECOG < 1 vs. 50 days for ECOG > 2, P < 0.001, respectively) in this intent-to-treat analysis. CONCLUSION The risk and the pattern of infectious complications at diagnosis and after initiation of AML therapy depends on age, ECOG performance status and subsequent treatment intensity. A comprehensive diagnostic work-up for identification of pulmonary IFD is indispensable for effective treatment of pneumonia in AML patients. The presence of infectious complications at diagnosis contributes to an inferior outcome in elderly AML patients.
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Affiliation(s)
- Romy Tober
- Klinik Für Innere Medizin II, Abteilung Hämatologie Und Internistische Onkologie, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Ulf Schnetzke
- Klinik Für Innere Medizin II, Abteilung Hämatologie Und Internistische Onkologie, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Maximilian Fleischmann
- Klinik Für Innere Medizin II, Abteilung Hämatologie Und Internistische Onkologie, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Olaposi Yomade
- Klinik Für Innere Medizin II, Abteilung Hämatologie Und Internistische Onkologie, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Karin Schrenk
- Klinik Für Innere Medizin II, Abteilung Hämatologie Und Internistische Onkologie, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Jakob Hammersen
- Klinik Für Innere Medizin II, Abteilung Hämatologie Und Internistische Onkologie, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Anita Glaser
- Institut Für Humangenetik, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Christian Thiede
- Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Germany
| | - Andreas Hochhaus
- Klinik Für Innere Medizin II, Abteilung Hämatologie Und Internistische Onkologie, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Sebastian Scholl
- Klinik Für Innere Medizin II, Abteilung Hämatologie Und Internistische Onkologie, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Germany.
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13
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Enzmann T, Albrecht K. [Fatal complications after urological interventions-connection between error, damage and causality]. UROLOGIE (HEIDELBERG, GERMANY) 2023; 62:252-255. [PMID: 36810700 DOI: 10.1007/s00120-023-02032-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/16/2023] [Indexed: 02/24/2023]
Abstract
Case studies from the clinic outline the connection between error, damage and causality. If the three "categories" mentioned are to be affirmed, recourse claims of the payers and the patients or their relatives are enforced in practice.
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Affiliation(s)
- T Enzmann
- Klinik für Urologie und Kinderurologie, Universitätsklinik Brandenburg an der Havel, Hochstr. 29, 14770, Brandenburg an der Havel, Deutschland.
| | - K Albrecht
- Brandenburgisches Landesinstitut für Rechtsmedizin (BLR), Potsdam, Deutschland.,Medizinische Hochschule Brandenburg (MHB), Neuruppin, Deutschland
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14
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[Acute management of anaphylaxis]. MMW Fortschr Med 2023; 165:48-55. [PMID: 36703064 DOI: 10.1007/s15006-022-2119-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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15
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Schmoch T, Möhnle P, Weigand MA, Briegel J, Bauer M, Bloos F, Meybohm P, Keh D, Löffler M, Elke G, Brenner T, Bogatsch H. The prevalence of sepsis-induced coagulopathy in patients with sepsis - a secondary analysis of two German multicenter randomized controlled trials. Ann Intensive Care 2023; 13:3. [PMID: 36635426 PMCID: PMC9837358 DOI: 10.1186/s13613-022-01093-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 12/05/2022] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Sepsis and septic shock are frequently accompanied by coagulopathy. Since the sepsis-induced coagulopathy (SIC) score was first described, subsequent studies from Asia revealed a SIC prevalence of 40-60%. In Europe, however, SIC prevalence in patients fulfilling sepsis criteria according to the third international consensus definition (SEPSIS-3) has not yet been evaluated. METHODS The Critical Care Trials Group of the German Sepsis Competence Network (SepNet) conducted a secondary analysis of two randomized controlled trials. Only patients fulfilling sepsis criteria according SEPSIS-3 were included in this secondary analysis. In a two step approach, SIC prevalence was determined in 267 patients with sepsis but not septic shock (at the time of inclusion) from the "Effect of Hydrocortisone on Development of Shock Among Patients With Severe Sepsis" (HYPRESS) trial. Then, we estimated SIC prevalence in 1,018 patients from the "Effect of Sodium Selenite Administration and Procalcitonin-Guided Therapy on Mortality in Patients With Severe Sepsis or Septic Shock" (SISPCT) trial using a simplified SIC score based on the platelet-SIC-subscore (PSSC). Study aims were to assess (i) the prevalence of SIC in patients with SEPSIS-3, (ii) the association of SIC with 90-day mortality and morbidity, (iii) the time when patients become SIC positive during the course of sepsis, and (iv) the value of the PSSC for predicting SIC. RESULTS In the HYPRESS trial, SIC prevalence was 22.1% (95% confidence interval [CI] 17.5-27.5%). The estimated SIC prevalence in the SISPCT trial was 24.2% (95% CI 21.6-26.9%). In the HYPRESS trial, SIC was associated with significantly higher 90-day mortality (13.9% vs. 26.8%, p = 0.027) and morbidity. Logistic regression analysis adjusted for age, sex, treatment arm, and (SIC-adapted) SOFA score confirmed the negative association of SIC with survival (p = 0.011). In the SISPCT trial, increased PSSCs were associated with higher 90-day mortality (PSSC 0: 34.4%, PSSC 1: 40.5%, PSSC 2: 53.3%; p < 0.001). In both trials, SIC was already present at sepsis diagnosis or occurred during the following 4 days. CONCLUSIONS SIC is a clinically relevant complication of sepsis. Although it might be less frequent than previously reported, its occurrence is associated with higher morbidity and mortality and should be interpreted as an early warning sign.
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Affiliation(s)
- Thomas Schmoch
- grid.414194.d0000 0004 0613 2450Department of Anesthesiology and Intensive Care Medicine, Hôpitaux Robert Schuman – Hôpital Kirchberg, 9, Rue Edward Steichen, 2540 Luxembourg City, Luxembourg ,grid.5718.b0000 0001 2187 5445Department of Anesthesiology and Intensive Care Medicine, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Patrick Möhnle
- grid.411095.80000 0004 0477 2585Department of Transfusion Medicine, Cell Therapeutics and Hemostasis, Department of Anesthesiology, Klinikum Der Ludwig-Maximilians-Universität, Munich, Germany
| | - Markus A. Weigand
- grid.5253.10000 0001 0328 4908Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Josef Briegel
- grid.411095.80000 0004 0477 2585Department of Anesthesiology, Klinikum Der Ludwig-Maximilians-Universität, Munich, Germany
| | - Michael Bauer
- grid.275559.90000 0000 8517 6224Center for Sepsis Control and Care, Jena University Hospital, Jena, Germany
| | - Frank Bloos
- grid.275559.90000 0000 8517 6224Center for Sepsis Control and Care, Jena University Hospital, Jena, Germany ,grid.275559.90000 0000 8517 6224Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - Patrick Meybohm
- grid.411760.50000 0001 1378 7891Department of Anesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Würzburg, Germany
| | - Didier Keh
- grid.6363.00000 0001 2218 4662Department of Anesthesiology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Markus Löffler
- Institute for Medical Informatics, Statistics and Epidemiology (IMISE) and Clinical Trial Centre Leipzig, Leipzig, Germany
| | - Gunnar Elke
- grid.412468.d0000 0004 0646 2097Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Thorsten Brenner
- grid.5718.b0000 0001 2187 5445Department of Anesthesiology and Intensive Care Medicine, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Holger Bogatsch
- Institute for Medical Informatics, Statistics and Epidemiology (IMISE) and Clinical Trial Centre Leipzig, Leipzig, Germany
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Bloos F. [Therapy of sepsis]. Anasthesiol Intensivmed Notfallmed Schmerzther 2023; 58:40-50. [PMID: 36623529 DOI: 10.1055/a-1813-2319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Sepsis as a development of an acute infection-related organ dysfunction significantly increases the risk of death for the patient. Therefore, fast and consistent management is required. The sepsis bundle is a convenient algorithm for initial sepsis therapy within the first hour of sepsis diagnosis consisting of blood cultures, lactate measurement, antibiotics, fluid resuscitation, and vasopressor therapy. Cristalloid solutions are first choice for fluid therapy but albumin and gelatine may be considered if colloid solutions are required. Norepinephrine is the vasopressor of first choice. After initial therapy, further fluid resuscitation should be guided by dynamic criteria. Vasopressin may be added as an additional vasopressor. Goal of resuscitation is to achieve lactate clearance. In shock refractory to therapy, addition of hydrocortisone (200 mg/day) should be considered. Further additional therapies such as immunoglobulins, blood purification, and metabolic resuscitation (combination of hydrocortisone, thiamine, vitamine C) are currently not supported by studies and should not be considered as standard therapy.
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Characteristics of bacterial infections and prevalence of multidrug-resistant bacteria in hospitalized patients with liver cirrhosis in Germany. Ann Hepatol 2022; 27:100719. [PMID: 35460883 DOI: 10.1016/j.aohep.2022.100719] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 04/04/2022] [Accepted: 04/11/2022] [Indexed: 02/04/2023]
Abstract
INTRODUCTION AND OBJECTIVES Bacterial infections are associated with a dismal prognosis in patients with liver cirrhosis. Data on their prevalence and the associated pathogen spectra in Germany are scarce. This study aimed to evaluate the impact of bacterial infections on mortality in hospitalized patients with liver cirrhosis and to analyze the prevalence of multidrug-resistant (MDR) bacteria in a German tertiary care center. PATIENTS AND METHODS Consecutive, non-electively hospitalized patients with liver cirrhosis were enrolled in this study between 03/2019-06/2021. All patients underwent clinical, laboratory and microbiological testing to detect potential bacterial infections. Patients were followed for 30 days regarding the composite endpoint of death or liver transplantation (mortality). RESULTS In total, 239 patients were recruited (median MELD 18). Bacterial infection was detected in 81 patients (33.9%) at study inclusion. A total of 70 patients (29.3%) developed a hospital-acquired infection. When comparing community-acquired and hospital-acquired infections, the pathogen pattern shifted from a gram-negative to a more gram-positive spectrum and showed an increase of Staphylococcus spp.. MDR bacteria were detected in seven infected patients (5.8%). 34 patients reached the composite endpoint during 30-days follow-up. In multivariable logistic regression analysis, the presence of infection during hospitalization remained independently associated with higher mortality (OR 2.522, 95% CI 1.044 - 6.091, p = 0.040). CONCLUSIONS This study demonstrates that bacterial infections are common in hospitalized patients with liver cirrhosis in Germany and are a major determinant of short-term mortality. Our data highlight the importance of regional differences in MDR bacteria and may guide physicians' decision-making regarding calculated antibiotic treatment.
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Mück A, Herter T. [69/m-Recurrent diverticulitis of the pelvic colon, tachypnea and altered mental status : Preparation course anesthesiological intensive care medicine: case 9]. DIE ANAESTHESIOLOGIE 2022; 71:48-55. [PMID: 35925178 DOI: 10.1007/s00101-022-01146-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/20/2022] [Indexed: 06/15/2023]
Affiliation(s)
- Alexander Mück
- Klinik für Anästhesiologie und operative Intensivmedizin, Universitätsklinikum Augsburg, Stenglinstraße 2, 86156, Augsburg, Deutschland.
| | - Tobias Herter
- Klinik für Anästhesie, Intensiv- & Notfallmedizin, St. Josefskrankenhaus Freiburg, Freiburg, Deutschland
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19
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Bartsch LA, Brenner T, Schmoch T. [65/m-Fever, reduced vigilance and increasing dyspnea : Preparation course anesthesiological intensive care medicine: case 16]. DIE ANAESTHESIOLOGIE 2022; 71:88-92. [PMID: 35925172 DOI: 10.1007/s00101-022-01137-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/19/2022] [Indexed: 06/15/2023]
Affiliation(s)
- Lorenz-Alexander Bartsch
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Essen, Universität Duisburg-Essen, Essen, Deutschland.
| | - Thorsten Brenner
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Essen, Universität Duisburg-Essen, Essen, Deutschland
| | - Thomas Schmoch
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Essen, Universität Duisburg-Essen, Essen, Deutschland
- Klinik für Anästhesiologie und Intensivmedizin, Hôpitaux Robert Schuman - Hôpital Kirchberg, Luxemburg, Luxemburg
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Dietrich M, Hölle T, Lalev LD, Loos M, Schmitt FCF, Fiedler MO, Hackert T, Richter DC, Weigand MA, Fischer D. Plasma Transfusion in Septic Shock—A Secondary Analysis of a Retrospective Single-Center Cohort. J Clin Med 2022; 11:jcm11154367. [PMID: 35955987 PMCID: PMC9369152 DOI: 10.3390/jcm11154367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 07/09/2022] [Accepted: 07/22/2022] [Indexed: 11/16/2022] Open
Abstract
In sepsis, both beneficial and detrimental effects of fresh frozen plasma (FFP) transfusion have been reported. The aim of this study was to analyze the indication for and effect of FFP transfusion in patients with septic shock. We performed a secondary analysis of a retrospective single-center cohort of all patients treated for septic shock at the interdisciplinary surgical intensive care unit (ICU) of the Heidelberg University Hospital. Septic shock was defined according to sepsis-3 criteria. To assess the effects of FFP administration in the early phase of septic shock, we compared patients with and without FFP transfusion during the first 48 h of septic shock. Patients who died during the first 48 h of septic shock were excluded from the analysis. Primary endpoints were 30- and 90-day mortality. A total of 261 patients were identified, of which 100 (38.3%) received FFP transfusion within the first 48 h after septic shock onset. The unmatched analysis showed a trend toward higher 30- and 90-d mortality in the FFP group (30 d: +7% p = 0.261; 90 d: +11.9% p = 0.061). In the propensity-matched analysis, 30- and 90-day mortality were similar between groups. Plasma administration did not influence fluid or vasopressor need, lactate levels, ICU stay, or days on a ventilator. We found no significant harm or associated benefit of FFP use in the early phase of septic shock. Finally, plasma should only be used in patients with a strong indication according to current recommendations, as a conclusive evaluation of the risk-benefit ratio for plasma transfusion in septic shock cannot be made based on the current data.
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Affiliation(s)
- Maximilian Dietrich
- Department of Anesthesiology, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany; (T.H.); (L.D.L.); (F.C.F.S.); (M.O.F.); (D.C.R.); (M.A.W.); (D.F.)
- Correspondence:
| | - Tobias Hölle
- Department of Anesthesiology, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany; (T.H.); (L.D.L.); (F.C.F.S.); (M.O.F.); (D.C.R.); (M.A.W.); (D.F.)
| | - Lazar Detelinov Lalev
- Department of Anesthesiology, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany; (T.H.); (L.D.L.); (F.C.F.S.); (M.O.F.); (D.C.R.); (M.A.W.); (D.F.)
| | - Martin Loos
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany; (M.L.); (T.H.)
| | - Felix Carl Fabian Schmitt
- Department of Anesthesiology, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany; (T.H.); (L.D.L.); (F.C.F.S.); (M.O.F.); (D.C.R.); (M.A.W.); (D.F.)
| | - Mascha Onida Fiedler
- Department of Anesthesiology, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany; (T.H.); (L.D.L.); (F.C.F.S.); (M.O.F.); (D.C.R.); (M.A.W.); (D.F.)
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany; (M.L.); (T.H.)
| | - Daniel Christoph Richter
- Department of Anesthesiology, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany; (T.H.); (L.D.L.); (F.C.F.S.); (M.O.F.); (D.C.R.); (M.A.W.); (D.F.)
| | - Markus Alexander Weigand
- Department of Anesthesiology, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany; (T.H.); (L.D.L.); (F.C.F.S.); (M.O.F.); (D.C.R.); (M.A.W.); (D.F.)
| | - Dania Fischer
- Department of Anesthesiology, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany; (T.H.); (L.D.L.); (F.C.F.S.); (M.O.F.); (D.C.R.); (M.A.W.); (D.F.)
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21
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Brinkmann A, Frey O. [Therapeutic drug monitoring and individualized antibiotic dosing-Tool or toy on the intensive care unit]. DIE ANAESTHESIOLOGIE 2022; 71:493-494. [PMID: 35925056 DOI: 10.1007/s00101-022-01174-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/23/2022] [Indexed: 06/17/2023]
Affiliation(s)
- Alexander Brinkmann
- Klinik für Anästhesie, operative Intensivmedizin und spezielle Schmerztherapie, Klinikum Heidenheim, Heidenheim, Deutschland.
| | - Otto Frey
- Apotheke des Klinikum Heidenheim, Heidenheim, Deutschland
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22
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Walker SV, Steffens B, Sander D, Wetsch WA. Implementation of Antibiotic Stewardship Improves the Quality of Blood Culture Diagnostics at an Intensive Care Unit of a University Hospital. J Clin Med 2022; 11:jcm11133675. [PMID: 35806960 PMCID: PMC9267444 DOI: 10.3390/jcm11133675] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 06/21/2022] [Accepted: 06/21/2022] [Indexed: 01/27/2023] Open
Abstract
Background: Bloodstream infections increase morbidity and mortality in hospitalized patients and pose a significant burden for health care systems worldwide. Optimal blood culture diagnostics are essential for early detection and specific treatment. After assessing the quality parameters at a surgical intensive care unit for six months, we implemented a diagnostic stewardship bundle (DSB) to optimize blood culture diagnostics and then reevaluated its effects after six months. Material and Methods: All patients ≥18 years old and on the ward were included: pre-DSB 137 and post-DSB 158. The standard quality parameters were defined as the number of blood culture sets per diagnostic episode (≥2), the rate of contamination (2–3%), the rate of positivity (5–15%), the collection site (≥1 venipuncture per episode) and the filling volume of the bottles (8–10 mL, only post-DSB). The DSB included an informational video, a standard operating procedure, and ready-to-use paper crates with three culture sets. Results: From pre- to post-interventional, the number of ≥2 culture sets per episode increased from 63.9% (257/402) to 81.3% (230/283), and venipunctures increased from 42.5% (171/402) to 77.4% (219/283). The positivity rate decreased from 15.1% (108/714) to 12.8% (83/650), as did the contamination rate (3.8% to 3.6%). The majority of the aerobic bottles were filled within the target range (255/471, 54.1%), but in 96.6%, the anaerobic bottles were overfilled (451/467). Conclusions: The implementation of DSB improved the quality parameters at the unit, thus optimizing the blood culture diagnostics. Further measures seem necessary to decrease the contamination rate and optimize bottle filling significantly.
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Affiliation(s)
- Sarah V. Walker
- Faculty of Medicine, University of Cologne, 50923 Cologne, Germany; (B.S.); (D.S.); (W.A.W.)
- Institute for Medical Microbiology, Immunology and Hygiene, University Hospital of Cologne, 50935 Cologne, Germany
- German Centre for Infection Research (DZIF), 38124 Braunschweig, Germany
- Correspondence:
| | - Benedict Steffens
- Faculty of Medicine, University of Cologne, 50923 Cologne, Germany; (B.S.); (D.S.); (W.A.W.)
- Institute for Medical Microbiology, Immunology and Hygiene, University Hospital of Cologne, 50935 Cologne, Germany
| | - David Sander
- Faculty of Medicine, University of Cologne, 50923 Cologne, Germany; (B.S.); (D.S.); (W.A.W.)
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Cologne, 50937 Cologne, Germany
| | - Wolfgang A. Wetsch
- Faculty of Medicine, University of Cologne, 50923 Cologne, Germany; (B.S.); (D.S.); (W.A.W.)
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Cologne, 50937 Cologne, Germany
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23
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Paquet D, Jung L, Trawinski H, Wendt S, Lübbert C. Fever in the Returning Traveler. DEUTSCHES ARZTEBLATT INTERNATIONAL 2022; 119:400-407. [PMID: 35469592 PMCID: PMC9492913 DOI: 10.3238/arztebl.m2022.0182] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 02/10/2022] [Accepted: 04/01/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND It is predicted that approximately two billion tourist trips to foreign countries will be taken worldwide each year by 2030. Germany has long been among the most active countries in tourism. The frequency of illness among persons returning from developing and newly industrialized countries is 43-79%. The appropriate diagnosis of fever in returning travelers is a clinically important matter, as it can be a sign of a life-threatening illness. METHODS This review is based on publications (2001-2022) retrieved by a selective search in PubMed for studies on the epidemiology, diagnosis, and treatment of febrile illnesses in returning travelers, or on specific tropical diseases. RESULTS Diarrhea, fever, and skin changes are the most common manifestations of disease after travel to tropical and sub - tropical areas. The diagnostic evaluation should be performed in a series of steps, beginning with a precise travel history and the identification of specific risk factors. Among travelers returning from sub-Saharan Africa, Plasmodium falciparum malaria is the most common cause of fever on presentation to centers for infectious diseases and tropical medicine, affecting approximately 50 per 1000 travelers. Among persons returning from travel to Southeast Asia, dengue fever is the most common infectious disease, affecting 50-160 per 1000 travelers. Further potentially dangerous diseases include chikungunya and zika fever, typhoid and paratyphoid fever, amoebic liver abscess, visceral leishmaniasis (kala-azar), leptospirosis, and, very rarely, imported cases of viral hemorrhagic fever. COVID-19 and influenza are important differential diagnoses. CONCLUSION The differential diagnosis can be narrowed by thorough history-taking with particular attention to the patient's travel route, combined with a good knowledge of the geographic spread and incubation times of the main tropical diseases. Algorithms help clinicians to focus the diagnostic work-up and select the appropriate further laboratory tests and diagnostic procedures.
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Affiliation(s)
- Dennis Paquet
- Department of Infectious Diseases/Tropical Medicine, Nephrology and Rheumatology, Klinikum St. Georg gGmbH, Leipzig, Germany
| | - Laura Jung
- Interdisciplinary Center for Infectious Diseases (ZINF), Leipzig University Hospital, Leipzig, Germany
- Division of Infectious Diseases and Tropical Medicine, Department of Oncology, Gastroenterology, Hepatology, Pneumology and Infectious Diseases, Leipzig University Hospital, Leipzig, Germany
| | - Henning Trawinski
- Interdisciplinary Center for Infectious Diseases (ZINF), Leipzig University Hospital, Leipzig, Germany
- Division of Infectious Diseases and Tropical Medicine, Department of Oncology, Gastroenterology, Hepatology, Pneumology and Infectious Diseases, Leipzig University Hospital, Leipzig, Germany
| | - Sebastian Wendt
- Interdisciplinary Center for Infectious Diseases (ZINF), Leipzig University Hospital, Leipzig, Germany
- Division of Infectious Diseases and Tropical Medicine, Department of Oncology, Gastroenterology, Hepatology, Pneumology and Infectious Diseases, Leipzig University Hospital, Leipzig, Germany
- Division of Microbiology, Institute of Medical Microbiology and Virology, Leipzig University Hospital, Leipzig, Germany
| | - Christoph Lübbert
- Department of Infectious Diseases/Tropical Medicine, Nephrology and Rheumatology, Klinikum St. Georg gGmbH, Leipzig, Germany
- Interdisciplinary Center for Infectious Diseases (ZINF), Leipzig University Hospital, Leipzig, Germany
- Division of Infectious Diseases and Tropical Medicine, Department of Oncology, Gastroenterology, Hepatology, Pneumology and Infectious Diseases, Leipzig University Hospital, Leipzig, Germany
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24
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Balke M, Teschler M, Schäfer H, Pape P, Mooren FC, Schmitz B. Therapeutic Potential of Electromyostimulation (EMS) in Critically Ill Patients—A Systematic Review. Front Physiol 2022; 13:865437. [PMID: 35615672 PMCID: PMC9124773 DOI: 10.3389/fphys.2022.865437] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 03/01/2022] [Indexed: 12/15/2022] Open
Abstract
Ample evidence exists that intensive care unit (ICU) treatment and invasive ventilation induce a transient or permanent decline in muscle mass and function. The functional deficit is often called ICU-acquired weakness with critical illness polyneuropathy (CIP) and/or myopathy (CIM) being the major underlying causes. Histopathological studies in ICU patients indicate loss of myosin filaments, muscle fiber necrosis, atrophy of both muscle fiber types as well as axonal degeneration. Besides medical prevention of risk factors such as sepsis, hyperglycemia and pneumonia, treatment is limited to early passive and active mobilization and one third of CIP/CIM patients discharged from ICU never regain their pre-hospitalization constitution. Electromyostimulation [EMS, also termed neuromuscular electrical stimulation (NMES)] is known to improve strength and function of healthy and already atrophied muscle, and may increase muscle blood flow and induce angiogenesis as well as beneficial systemic vascular adaptations. This systematic review aimed to investigate evidence from randomized controlled trails (RCTs) on the efficacy of EMS to improve the condition of critically ill patients treated on ICU. A systematic search of the literature was conducted using PubMed (Medline), CENTRAL (including Embase and CINAHL), and Google Scholar. Out of 1,917 identified records, 26 articles (1,312 patients) fulfilled the eligibility criteria of investigating at least one functional measure including muscle function, functional independence, or weaning outcomes using a RCT design in critically ill ICU patients. A qualitative approach was used, and results were structured by 1) stimulated muscles/muscle area (quadriceps muscle only; two to four leg muscle groups; legs and arms; chest and abdomen) and 2) treatment duration (≤10 days, >10 days). Stimulation parameters (impulse frequency, pulse width, intensity, duty cycle) were also collected and the net EMS treatment time was calculated. A high grade of heterogeneity between studies was detected with major cofactors being the analyzed patient group and selected outcome variable. The overall efficacy of EMS was inconclusive and neither treatment duration, stimulation site or net EMS treatment time had clear effects on study outcomes. Based on our findings, we provide practical recommendations and suggestions for future studies investigating the therapeutic efficacy of EMS in critically ill patients. Systematic Review Registration: [https://www.crd.york.ac.uk/prospero/], identifier [CRD42021262287].
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Affiliation(s)
- Maryam Balke
- St. Marien Hospital Cologne, Department of Early Rehabilitation, Cologne, Germany
- Department of Rehabilitation Sciences, Faculty of Health, University of Witten/Herdecke, Witten, Germany
- *Correspondence: Maryam Balke,
| | - Marc Teschler
- Department of Rehabilitation Sciences, Faculty of Health, University of Witten/Herdecke, Witten, Germany
- DRV Clinic Königsfeld, Center for Medical Rehabilitation, Ennepetal, Germany
| | - Hendrik Schäfer
- Department of Rehabilitation Sciences, Faculty of Health, University of Witten/Herdecke, Witten, Germany
- DRV Clinic Königsfeld, Center for Medical Rehabilitation, Ennepetal, Germany
| | - Pantea Pape
- St. Marien Hospital Cologne, Department of Early Rehabilitation, Cologne, Germany
| | - Frank C. Mooren
- Department of Rehabilitation Sciences, Faculty of Health, University of Witten/Herdecke, Witten, Germany
- DRV Clinic Königsfeld, Center for Medical Rehabilitation, Ennepetal, Germany
| | - Boris Schmitz
- Department of Rehabilitation Sciences, Faculty of Health, University of Witten/Herdecke, Witten, Germany
- DRV Clinic Königsfeld, Center for Medical Rehabilitation, Ennepetal, Germany
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25
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Rauch-Kröhnert U, Riess H. [Anticoagulation in coronavirus disease 2019 (COVID-19): confirmed and controversial aspects]. Internist (Berl) 2022; 63:453-460. [PMID: 35290499 PMCID: PMC8922984 DOI: 10.1007/s00108-022-01296-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/09/2022] [Indexed: 01/08/2023]
Abstract
Infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is associated with a high risk of microvascular immunothrombosis as well as symptomatic and incidental thromboembolisms, predominantly in the venous system but also in the arterial system. This explains among other things the high cardiovascular morbidity and mortality of the patients. The present state of knowledge on the pathophysiology of immunothrombosis and the strategies of anticoagulation in patients with coronavirus disease 2019 (COVID-19) are summarized and illuminated in this article. According to the current guidelines moderately to severely ill patients who are being treated in hospital should receive thrombosis prophylaxis with low molecular weight or unfractionated heparin or alternatively with fondaparinux, as long as there is no clearly increased risk of bleeding. Apart from the established indications for treatment, an intensified or therapeutic dose prophylaxis should be considered very cautiously in these critically ill patients, also due to the increased bleeding complications. The routine continuation of prophylactic anticoagulation after discharge from hospital is currently not recommended.
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Affiliation(s)
- Ursula Rauch-Kröhnert
- Klinik für Kardiologie, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, Hindenburgdamm 30, 12200, Berlin, Deutschland.
| | - Hanno Riess
- Medizinische Klinik m. S. Hämatologie, Onkologie und Tumorimmunologie, Campus Charité Mitte, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Deutschland
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26
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Klein M, Schröder H, Beckers SK, Borgs C, Rossaint R, Felzen M. [Quality of documentation and treatment in the non-physician staffed ambulance: a retrospective analysis of emergency protocols from the city of Aachen]. Anaesthesist 2022; 71:674-682. [PMID: 35316370 PMCID: PMC9427917 DOI: 10.1007/s00101-022-01106-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 12/28/2021] [Accepted: 01/27/2022] [Indexed: 11/28/2022]
Abstract
Hintergrund Der deutsche Rettungsdienst wird jährlich zu ca. 7,3 Mio. Einsätzen alarmiert, welche zu einem Großteil (ca. 59 %) ohne Arzt ablaufen. Da kaum Daten zur Qualität der medizinischen Versorgung und Dokumentation von Rettungsdiensteinsätzen ohne Arzt vorliegen, sollen diese anhand der Einsatzprotokolle im Rahmen dieser Studie überprüft werden. Methode Es erfolgte eine retrospektive Analyse von Protokollen der Rettungsdiensteinsätze ohne Arzt aus den Monaten Juni und Juli 2018. Unter Einbezug von Verfahrensanweisungen wurden die Dokumentations- und Behandlungsqualität der Einsätze analysiert. Primäre Endpunkte waren Dokumentationshäufigkeit, Vollständigkeit, die korrekte Notarzt- oder Telenotarztindikationsstellung, die Entwicklung von kritischen Vitalparametern im Einsatzverlauf sowie die mediane Behandlungszeit. Ergebnisse Insgesamt wurden 1935 Protokolle ausgewertet. Die Verdachtsdiagnose wurde in 1323 (68,4 %), die Anamnese in 456 (23,6 %), der Erstbefund in 350 (18,1 %) und der Letztbefund in 52 (2,7 %) der Fälle vollständig dokumentiert. Anhand der Dokumentation bestand bei 531 (27 %) Patienten eine Telenotarzt- bzw. Notarztindikation, jedoch kein Arztkontakt. Bei diesen Patienten wurden 410 kritische Vitalparameter im Erstbefund dokumentiert. Von diesen Vitalwerten verbesserten sich 69 (16,8 %); bei 217 (52,9 %) wurde kein Übergabebefund dokumentiert. Die mediane Behandlungsdauer vor Ort war bei Patienten mit eigentlicher Notarztindikation (15:02 min) signifikant länger als bei Patienten ohne Indikation (13:05 min). Schlussfolgerung Die Dokumentation der Einsätze ist defizitär. Zudem könnte ein Viertel der Patienten von einem prähospitalen Arztkontakt profitieren. Eine juristisch bedenkliche Übergabedokumentation besteht bei ca. der Hälfte aller Protokolle.
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Affiliation(s)
- Maximilian Klein
- Klinik für Anästhesiologie, Medizinische Fakultät, RWTH Aachen University, Uniklinik RWTH Aachen, Aachen, Deutschland
| | - Hanna Schröder
- Klinik für Anästhesiologie, Medizinische Fakultät, RWTH Aachen University, Uniklinik RWTH Aachen, Aachen, Deutschland.,Aachener Institut für Rettungsmedizin und Zivile Sicherheit, Uniklinik RWTH Aachen & Stadt Aachen, Aachen, Deutschland
| | - Stefan K Beckers
- Klinik für Anästhesiologie, Medizinische Fakultät, RWTH Aachen University, Uniklinik RWTH Aachen, Aachen, Deutschland.,Aachener Institut für Rettungsmedizin und Zivile Sicherheit, Uniklinik RWTH Aachen & Stadt Aachen, Aachen, Deutschland.,Ärztliche Leitung Rettungsdienst, Berufsfeuerwehr Aachen, Stadt Aachen, Stolberger Str. 155, 52068, Aachen, Deutschland
| | - Christina Borgs
- Klinik für Anästhesiologie, Medizinische Fakultät, RWTH Aachen University, Uniklinik RWTH Aachen, Aachen, Deutschland.,Aachener Institut für Rettungsmedizin und Zivile Sicherheit, Uniklinik RWTH Aachen & Stadt Aachen, Aachen, Deutschland
| | - Rolf Rossaint
- Klinik für Anästhesiologie, Medizinische Fakultät, RWTH Aachen University, Uniklinik RWTH Aachen, Aachen, Deutschland
| | - Marc Felzen
- Klinik für Anästhesiologie, Medizinische Fakultät, RWTH Aachen University, Uniklinik RWTH Aachen, Aachen, Deutschland. .,Aachener Institut für Rettungsmedizin und Zivile Sicherheit, Uniklinik RWTH Aachen & Stadt Aachen, Aachen, Deutschland. .,Ärztliche Leitung Rettungsdienst, Berufsfeuerwehr Aachen, Stadt Aachen, Stolberger Str. 155, 52068, Aachen, Deutschland.
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27
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Berner R, Sawicki J, Thiele M, Löser T, Schöll E. Critical Parameters in Dynamic Network Modeling of Sepsis. FRONTIERS IN NETWORK PHYSIOLOGY 2022; 2:904480. [PMID: 36926088 PMCID: PMC10012967 DOI: 10.3389/fnetp.2022.904480] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 05/03/2022] [Indexed: 11/13/2022]
Abstract
In this work, we propose a dynamical systems perspective on the modeling of sepsis and its organ-damaging consequences. We develop a functional two-layer network model for sepsis based upon the interaction of parenchymal cells and immune cells via cytokines, and the coevolutionary dynamics of parenchymal, immune cells, and cytokines. By means of the simple paradigmatic model of phase oscillators in a two-layer system, we analyze the emergence of organ threatening interactions between the dysregulated immune system and the parenchyma. We demonstrate that the complex cellular cooperation between parenchyma and stroma (immune layer) either in the physiological or in the pathological case can be related to dynamical patterns of the network. In this way we explain sepsis by the dysregulation of the healthy homeostatic state (frequency synchronized) leading to a pathological state (desynchronized or multifrequency cluster) in the parenchyma. We provide insight into the complex stabilizing and destabilizing interplay of parenchyma and stroma by determining critical interaction parameters. The coupled dynamics of parenchymal cells (metabolism) and nonspecific immune cells (response of the innate immune system) is represented by nodes of a duplex layer. Cytokine interaction is modeled by adaptive coupling weights between nodes representing immune cells (with fast adaptation timescale) and parenchymal cells (slow adaptation timescale), and between pairs of parenchymal and immune cells in the duplex network (fixed bidirectional coupling). The proposed model allows for a functional description of organ dysfunction in sepsis and the recurrence risk in a plausible pathophysiological context.
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Affiliation(s)
- Rico Berner
- Institut für Physik, Humboldt-Universität zu Berlin, Berlin, Germany.,Institut für Theoretische Physik, Technische Universität Berlin, Berlin, Germany
| | - Jakub Sawicki
- Institut für Theoretische Physik, Technische Universität Berlin, Berlin, Germany.,Potsdam Institute for Climate Impact Research, Potsdam, Germany.,Fachhochschule Nordwestschweiz FHNW, Basel, Switzerland
| | - Max Thiele
- Institut für Theoretische Physik, Technische Universität Berlin, Berlin, Germany
| | | | - Eckehard Schöll
- Institut für Theoretische Physik, Technische Universität Berlin, Berlin, Germany.,Potsdam Institute for Climate Impact Research, Potsdam, Germany.,Bernstein Center for Computational Neuroscience Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
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28
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Kluge S, Janssens U, Welte T, Weber-Carstens S, Schälte G, Salzberger B, Gastmeier P, Langer F, Welper M, Westhoff M, Pfeifer M, Hoffmann F, Böttiger BW, Marx G, Karagiannidis C. Recommendations for treatment of critically ill patients with COVID-19 : Version 3 S1 guideline. Anaesthesist 2021; 70:19-29. [PMID: 33245382 PMCID: PMC7694585 DOI: 10.1007/s00101-020-00879-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Since December 2019 a novel coronavirus (severe acute respiratory syndrome coronavirus 2, SARS-CoV-2) has rapidly spread around the world resulting in an acute respiratory illness pandemic. The immense challenges for clinicians and hospitals as well as the strain on many healthcare systems has been unprecedented.The majority of patients present with mild symptoms of coronavirus disease 2019 (COVID-19); however, 5-8% become critically ill and require intensive care treatment. Acute hypoxemic respiratory failure with severe dyspnea and an increased respiratory rate (>30/min) usually leads to intensive care unit (ICU) admission. At this point bilateral pulmonary infiltrates are typically seen. Patients often develop a severe acute respiratory distress syndrome (ARDS).So far, remdesivir and dexamethasone have shown clinical effectiveness in severe COVID-19 in hospitalized patients. The main goal of supportive treatment is to ascertain adequate oxygenation. Invasive mechanical ventilation and repeated prone positioning are key elements in treating severely hypoxemic COVID-19 patients.Strict adherence to basic infection control measures (including hand hygiene) and correct use of personal protection equipment (PPE) are essential in the care of patients. Procedures that lead to formation of aerosols should be carried out with utmost precaution and preparation.
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Affiliation(s)
- S Kluge
- Deutsche Gesellschaft für Internistische Intensivmedizin und Notfallmedizin (DGIIN), Berlin, Germany.
- Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin (DIVI), Berlin, Germany.
- Deutsche Gesellschaft für Pneumologie und Beatmungsmedizin (DGP), Berlin, Germany.
- ARDS Netzwerk Deutschland, Berlin, Germany.
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
| | - U Janssens
- Deutsche Gesellschaft für Internistische Intensivmedizin und Notfallmedizin (DGIIN), Berlin, Germany
- Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin (DIVI), Berlin, Germany
- ARDS Netzwerk Deutschland, Berlin, Germany
| | - T Welte
- Deutsche Gesellschaft für Internistische Intensivmedizin und Notfallmedizin (DGIIN), Berlin, Germany
- Deutsche Gesellschaft für Pneumologie und Beatmungsmedizin (DGP), Berlin, Germany
- ARDS Netzwerk Deutschland, Berlin, Germany
| | - S Weber-Carstens
- Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin (DIVI), Berlin, Germany
- Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI), Nürnberg, Germany
- ARDS Netzwerk Deutschland, Berlin, Germany
| | - G Schälte
- Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI), Nürnberg, Germany
| | - B Salzberger
- Deutsche Gesellschaft für Infektiologie (DGI), Munich, Germany
| | - P Gastmeier
- Deutsche Gesellschaft für Hygiene und Mikrobiologie (DGHM), Münster, Germany
| | - F Langer
- Gesellschaft für Thrombose und Hämostaseforschung (GTH), Cologne, Germany
| | - M Welper
- Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI), Nürnberg, Germany
| | - M Westhoff
- Deutsche Gesellschaft für Pneumologie und Beatmungsmedizin (DGP), Berlin, Germany
| | - M Pfeifer
- Deutsche Gesellschaft für Pneumologie und Beatmungsmedizin (DGP), Berlin, Germany
| | - F Hoffmann
- Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin (DIVI), Berlin, Germany
- Deutsche Gesellschaft für Kinder- und Jugendmedizin (DGKJ), Berlin, Germany
| | - B W Böttiger
- Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin (DIVI), Berlin, Germany
- Deutscher Rat für Wiederbelebung (German Resuscitation Council, GRC), Ulm, Germany
| | - G Marx
- Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin (DIVI), Berlin, Germany
- Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI), Nürnberg, Germany
- ARDS Netzwerk Deutschland, Berlin, Germany
| | - C Karagiannidis
- Deutsche Gesellschaft für Internistische Intensivmedizin und Notfallmedizin (DGIIN), Berlin, Germany
- Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin (DIVI), Berlin, Germany
- Deutsche Gesellschaft für Pneumologie und Beatmungsmedizin (DGP), Berlin, Germany
- ARDS Netzwerk Deutschland, Berlin, Germany
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Neuenfeldt FS, Weigand MA, Fischer D. Coagulopathies in Intensive Care Medicine: Balancing Act between Thrombosis and Bleeding. J Clin Med 2021; 10:5369. [PMID: 34830667 PMCID: PMC8623639 DOI: 10.3390/jcm10225369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 11/10/2021] [Accepted: 11/16/2021] [Indexed: 11/23/2022] Open
Abstract
Patient Blood Management advocates an individualized treatment approach, tailored to each patient's needs, in order to reduce unnecessary exposure to allogeneic blood products. The optimization of hemostasis and minimization of blood loss is of high importance when it comes to critical care patients, as coagulopathies are a common phenomenon among them and may significantly impact morbidity and mortality. Treating coagulopathies is complex as thrombotic and hemorrhagic conditions may coexist and the medications at hand to modulate hemostasis can be powerful. The cornerstones of coagulation management are an appropriate patient evaluation, including the individual risk of bleeding weighed against the risk of thrombosis, a proper diagnostic work-up of the coagulopathy's etiology, treatment with targeted therapies, and transfusion of blood product components when clinically indicated in a goal-directed manner. In this article, we will outline various reasons for coagulopathy in critical care patients to highlight the aspects that need special consideration. The treatment options outlined in this article include anticoagulation, anticoagulant reversal, clotting factor concentrates, antifibrinolytic agents, desmopressin, fresh frozen plasma, and platelets. This article outlines concepts with the aim of the minimization of complications associated with coagulopathies in critically ill patients. Hereditary coagulopathies will be omitted in this review.
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Affiliation(s)
| | | | - Dania Fischer
- Department of Anaesthesiology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (F.S.N.); (M.A.W.)
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Englbrecht JS, Lanckohr C, Ertmer C, Zarbock A. [Perioperative management of the brain-dead organ donor : Anesthesia between ethics and evidence]. Anaesthesist 2021; 71:384-391. [PMID: 34748026 PMCID: PMC9068648 DOI: 10.1007/s00101-021-01065-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/18/2021] [Indexed: 11/29/2022]
Abstract
Hintergrund Die Anzahl postmortal gespendeter Organe ist in Deutschland weit geringer als der Bedarf. Dies unterstreicht die Wichtigkeit einer optimalen Versorgung während des gesamten Prozesses der Organspende. Fragestellung Es existieren internationale Leitlinien und nationale Empfehlungen zu intensivmedizinischen organprotektiven Maßnahmen beim Organspender. Für das anästhesiologische Management fehlen evidenzbasierte Empfehlungen. Ziel dieser Übersichtsarbeit ist es, anhand der vorhandenen Evidenz die pathophysiologischen Veränderungen des irreversiblen Hirnfunktionsausfalls zu rekapitulieren und sich kritisch mit den empfohlenen Behandlungsstrategien und therapeutischen Zielgrößen auseinanderzusetzen. Auch auf ethische Aspekte der Betreuung des postmortalen Organspenders wird eingegangen. Methode Diese Übersichtsarbeit basiert auf einer selektiven Literaturrecherche in PubMed (Suchwörter: „brain dead donor“, „organ procurement“, „organ protective therapy“, „donor preconditioning“, „perioperative donor management“, „ethical considerations of brain dead donor“). Internationale Leitlinien und nationale Empfehlungen wurden besonders berücksichtigt. Ergebnisse Insgesamt ist die Evidenz für optimale intensivmedizinische und perioperative organprotektive Maßnahmen beim postmortalen Organspender sehr gering. Nationale und internationale Empfehlungen zu Zielwerten und medikamentösen Behandlungsstrategien unterscheiden sich teilweise erheblich: kontrollierte randomisierte Studien fehlen. Der Stellenwert einer Narkose zur Explantation bleibt sowohl unter pathophysiologischen Gesichtspunkten als auch aus ethischer Sicht ungeklärt. Schlussfolgerungen Die Kenntnisse über die pathophysiologischen Prozesse im Rahmen des irreversiblen Hirnfunktionsausfalls und die organprotektiven Maßnahmen sind ebenso Grundvoraussetzung wie die ethische Auseinandersetzung mit dem Thema postmortale Organspende. Nur dann kann das Behandlungsteam in dieser herausfordernden Situation sowohl dem Organempfänger als auch dem Organspender und seinen Angehörigen gerecht werden.
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Affiliation(s)
- Jan Sönke Englbrecht
- Klinik für Anästhesiologie, operative Intensivmedizin und Schmerztherapie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Deutschland.
| | - Christian Lanckohr
- Antibiotic Stewardship (ABS)-Team, Institut für Hygiene, Universitätsklinikum Münster, Münster, Deutschland
| | - Christian Ertmer
- Klinik für Anästhesiologie, operative Intensivmedizin und Schmerztherapie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Deutschland
| | - Alexander Zarbock
- Klinik für Anästhesiologie, operative Intensivmedizin und Schmerztherapie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Deutschland
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Brenner T, Skarabis A, Stevens P, Axnick J, Haug P, Grumaz S, Bruckner T, Luntz S, Witzke O, Pletz MW, Ruprecht TM, Marschall U, Altin S, Greiner W, Berger MM. Optimization of sepsis therapy based on patient-specific digital precision diagnostics using next generation sequencing (DigiSep-Trial)-study protocol for a randomized, controlled, interventional, open-label, multicenter trial. Trials 2021; 22:714. [PMID: 34663439 PMCID: PMC8522064 DOI: 10.1186/s13063-021-05667-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 09/28/2021] [Indexed: 12/19/2022] Open
Abstract
Background Sepsis is triggered by an infection and represents one of the greatest challenges of modern intensive care medicine. With regard to a targeted antimicrobial treatment strategy, the earliest possible pathogen detection is of crucial importance. Until now, culture-based detection methods represent the diagnostic gold standard, although they are characterized by numerous limitations. Culture-independent molecular diagnostic procedures represent a promising alternative. In particular, the plasmatic detection of circulating, cell-free DNA by next-generation sequencing (NGS) has shown to be suitable for identifying disease-causing pathogens in patients with bloodstream infections. Methods The DigiSep-Trial is a randomized, controlled, interventional, open-label, multicenter trial characterizing the effect of the combination of NGS-based digital precision diagnostics with standard-of-care microbiological analyses compared to solely standard-of-care microbiological analyses in the clinical picture of sepsis/septic shock. Additional anti-infective expert consultations are provided for both study groups. In 410 patients (n = 205 per arm) with sepsis/septic shock, the study examines whether the so-called DOOR-RADAR (Desirability of Outcome Ranking/Response Adjusted for Duration of Antibiotic Risk) score (representing a combined endpoint including the criteria (1) intensive/intermediate care unit length of stay, (2) consumption of antibiotics, (3) mortality, and (4) acute kidney injury (AKI)) can be improved by an additional NGS-based diagnostic concept. We also aim to investigate the cost-effectiveness of this new diagnostic procedure. It is postulated that intensive/intermediate care unit length of stay, mortality rate, incidence of AKI, the duration of antimicrobial therapy as well as the costs caused by complications and outpatient aftercare can be reduced. Moreover, a significant improvement in patient’s quality of life is expected. Discussion The authors´ previous work suggests that NGS-based diagnostics have a higher specificity and sensitivity compared to standard-of-care microbiological analyses for detecting bloodstream infections. In combination with the here presented DigiSep-Trial, this work provides the optimal basis to establish a new NGS-driven concept as part of the national standard based on the best possible evidence. Trial registrations DRKS-ID DRKS00022782. Registered on August 25, 2020 ClinicalTrials.govNCT04571801. Registered October 1, 2020 Supplementary Information The online version contains supplementary material available at 10.1186/s13063-021-05667-x.
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Affiliation(s)
- Thorsten Brenner
- Department of Anesthesiology and Intensive Care Medicine, Essen University Hospital, University Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Germany.
| | - Annabell Skarabis
- Department of Anesthesiology and Intensive Care Medicine, Essen University Hospital, University Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Germany
| | | | | | - Peter Haug
- Noscendo GmbH, Königstraße 34, 47198, Duisburg, Germany
| | - Silke Grumaz
- Noscendo GmbH, Königstraße 34, 47198, Duisburg, Germany
| | - Thomas Bruckner
- Institute of Medical Biometry, University of Heidelberg, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany
| | - Steffen Luntz
- Coordination Centre for Clinical Trials (KKS), Ruprecht-Karls-University, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany
| | - Oliver Witzke
- Department of Infectious Diseases, University Hospital Essen, University Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Germany
| | - Mathias W Pletz
- Center for Infectious Diseases and Infection Control, Jena University Hospital, Erlanger Allee 101, 07740, Jena, Germany
| | - Thomas M Ruprecht
- Techniker Krankenkasse, Bramfelder Str. 140, 22305, Hamburg, Germany
| | | | - Sibel Altin
- AOK Rheinland/Hamburg, Kasernenstr. 61, 40213, Düsseldorf, Germany
| | - Wolfgang Greiner
- Health Economics and Health Care Management, Bielefeld University, P.O. Box 10 01 31, 33501, Bielefeld, Germany
| | - Marc Moritz Berger
- Department of Anesthesiology and Intensive Care Medicine, Essen University Hospital, University Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Germany
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Keller M, Magunia H. [Vasopressors: Physiology, Pharmacology and Clinical Applications]. Anasthesiol Intensivmed Notfallmed Schmerzther 2021; 56:400-413. [PMID: 34187073 DOI: 10.1055/a-1214-4472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Vasopressors are widely used in anaesthesiology and critical care medicine, to treat harmless (e.g. anaesthesia-induced hypotension) as well as life-threatening conditions (e.g. septic shock). Some clinically used vasopressors resemble endogenous substances - such as norepinephrine - while others have been artificially synthesized (e.g. phenylephrine). Most of the substances used in different clinical scenarios have various effects except for vasoconstriction alone. Therefore, a thorough understanding of the pharmacology and clinical profile of every single substance is of highest importance prior to practical usage. Furthermore, the fundamentals of vascular physiology and vasotonic regulation are mandatory to safely provide vasopressor-based therapies. This article covers the essentials of physiology and pharmacology of vasopressors, and the clinical settings they are used in (e.g. septic shock, vasoplegic shock after cardiac surgery, trauma-induced hypotension).
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Richter DC, Dietrich M, Lalev LD, Schmitt FCF, Fiedler MO, Bruckner T, Stoerzinger D, Chiriac U, Klein S, Hackert T, Brenner T, Brinkmann A, Weigand MA. Prolonged Infusion of β-Lactams Decreases Mortality in Patients with Septic Shock: A Retrospective before-and-after Study. Antibiotics (Basel) 2021; 10:antibiotics10060687. [PMID: 34201244 PMCID: PMC8229114 DOI: 10.3390/antibiotics10060687] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 06/04/2021] [Accepted: 06/07/2021] [Indexed: 02/07/2023] Open
Abstract
Septic shock substantially alters the pharmacokinetic properties of β-lactams with a subsequently high risk of insufficiently low serum concentrations and treatment failure. Considering their pharmacokinetic (PK)/pharmacodynamic (PD) index, prolonged infusions (PI) of β-lactams extend the time that the unbound fraction of the drug remains above the minimal inhibitory concentration MIC (ft >MIC) and may improve patient survival. The present study is a monocentric, retrospective before-and-after analysis of septic shock patients treated with β-lactams. Patients of the years 2015–2017 received intermittent bolus application whereas patients of 2017–2020 received PI of β-lactams. The primary outcome was mortality at day 30 and 90 after diagnosis of septic shock. Mortality rates in the PI group were significantly lower on day 30 (PI: 41%, n = 119/290 vs. IB: 54.8%, n = 68/114; p = 0.0097) and day 90 (PI: 47.9%, n = 139/290 vs. IB: 62.9%, n = 78/124; p = 0.005). After propensity-score matching, 30- and 90-day mortality remained lower for the PI group (−10%, p = 0.14). PI was further associated with a reduction in the duration of invasive ventilation and a stronger decrease in SOFA scores within a 14 day-observation period. PI of β-lactams was associated with a significant reduction of mortality in patients with septic shock and may have beneficial effects on invasive ventilation and recovery from sepsis-related organ failure.
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Affiliation(s)
- Daniel Christoph Richter
- Department of Anesthesiology, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany; (L.D.L.); (F.C.F.S.); (M.O.F.); (M.A.W.)
- Correspondence: (D.C.R.); (M.D.)
| | - Maximilian Dietrich
- Department of Anesthesiology, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany; (L.D.L.); (F.C.F.S.); (M.O.F.); (M.A.W.)
- Correspondence: (D.C.R.); (M.D.)
| | - Lazar Detelinov Lalev
- Department of Anesthesiology, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany; (L.D.L.); (F.C.F.S.); (M.O.F.); (M.A.W.)
| | - Felix C. F. Schmitt
- Department of Anesthesiology, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany; (L.D.L.); (F.C.F.S.); (M.O.F.); (M.A.W.)
| | - Mascha Onida Fiedler
- Department of Anesthesiology, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany; (L.D.L.); (F.C.F.S.); (M.O.F.); (M.A.W.)
| | - Thomas Bruckner
- Institute of Medical Biometry & Biostatistics, Im Neuenheimer Feld 130.3, 69120 Heidelberg, Germany;
| | - Dominic Stoerzinger
- Department of Pharmacy, Heidelberg University Hospital, Im Neuenheimer Feld 670, 69120 Heidelberg, Germany; (D.S.); (U.C.)
| | - Ute Chiriac
- Department of Pharmacy, Heidelberg University Hospital, Im Neuenheimer Feld 670, 69120 Heidelberg, Germany; (D.S.); (U.C.)
| | - Sabrina Klein
- Department of Infectious Diseases, Medical Microbiology and Hygiene, Im Neuenheimer Feld 324, 69120 Heidelberg, Germany;
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany;
| | - Thorsten Brenner
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Essen, University Duisburg-Essen, Hufelandstraße 55, 45147 Essen, Germany;
| | - Alexander Brinkmann
- Department of Anesthesiology, Heidenheim Hospital, Schloßhaustraße 100, 89522 Heidenheim, Germany;
| | - Markus A. Weigand
- Department of Anesthesiology, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany; (L.D.L.); (F.C.F.S.); (M.O.F.); (M.A.W.)
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Cefiderocol in Critically Ill Patients with Multi-Drug Resistant Pathogens: Real-Life Data on Pharmacokinetics and Microbiological Surveillance. Antibiotics (Basel) 2021; 10:antibiotics10060649. [PMID: 34071700 PMCID: PMC8226704 DOI: 10.3390/antibiotics10060649] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 05/17/2021] [Accepted: 05/24/2021] [Indexed: 02/07/2023] Open
Abstract
Cefiderocol is a new siderophore-cephalosporin for the treatment of multi-drug resistant Gram-negative pathogens. As a reserve agent, it will and should be used primarily in critically ill patients in the upcoming years. Due to the novelty of the substance little data on the pharmacokinetics in critically ill patients with septic shock and renal failure (including continuous renal replacement therapy and cytokine adsorber therapy) is available. We performed therapeutic drug monitoring in a cohort of five patients treated with cefiderocol, to improve the knowledge on pharmacokinetics in this vulnerable patient population. As expected for a cephalosporin with predominantly renal elimination the maintenance dose could be reduced in patients with renal impairment or on continuous renal replacement therapy. The manufacturer’s dosing instructions were sufficient to achieve a drug level well above the MIC. However, the addition of a cytokine adsorber might reduce serum levels substantially, so that in this context therapeutic drug monitoring and dose adjustment are recommended.
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35
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Müller S, Wiesmann T, Wulf H, Arndt C. [Vitamin C - New Option in Sepsis Therapy?]. Anasthesiol Intensivmed Notfallmed Schmerzther 2021; 56:374-382. [PMID: 34038976 DOI: 10.1055/a-1109-4363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Vitamin C deficiency often occurs in critical illness and especially in patients with sepsis. Low plasma levels correlate with organ dysfunction and outcome parameters. Vitamin C offers pleiotropic effects possibly attenuating pathophysiology in sepsis. This includes antioxidative effects like scavenging reactive oxygen species or restoring other antioxidants. Vitamin C is a cofactor for norepinephrine biosynthesis and it protects endothelial function. In addition, it modulates immune response. A combined therapy with vitamin C, hydrocortisone and thiamine could be beneficial because of synergistic effects. Some clinical studies have shown reduced mortality due to vitamin C alone or in combination with hydrocortisone and thiamine, others do not. Adverse events are rare. So data supporting a therapy with vitamin C is still unclear. Further randomised controlled trials are necessary.
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36
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Ogica A, Burdelski C, Rohde H, Kluge S, de Heer G. Necrotizing Soft Tissue Infections in Intensive Care. J Intensive Care Med 2021; 37:393-400. [PMID: 33896254 PMCID: PMC8772247 DOI: 10.1177/08850666211010127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background: Necrotizing soft tissue infections (NSTIs) are typically characterized by extensive soft tissue destruction with systemic signs of toxicity, ranging from sepsis to septic shock. Our aim was to analyze the clinical characteristics, microbiological results, laboratory data, therapies, and outcome of patients with NSTIs admitted to an intensive care unit (ICU). Methods: A monocentric observational study of patients admitted to the ICU of a university hospital between January 2009 and December 2017. The demographic characteristics, comorbidities, clinical features, microbiology and laboratory results, organ dysfunctions, therapies, and outcome were retrospectively analyzed. Results: There were 59 patients and 70% males. The mean age (± SD) was 55 ± 18; type II (monomicrobial) NSTI was present in 36 patients (61%); the most common isolated pathogen was Streptococcus pyogenes in 28 patients (48%). Septic shock was diagnosed in 41 patients (70%). The most common organ dysfunctions were circulatory and renal in 42 (71%) and 38 patients (64%). The mean value (± SD) of serum lactate at admission to the ICU was 4.22 ± 5.42 mmol/l, the median SOFA score and SAPS II were 7 (IQR 4 - 10) and 46 (IQR 30.5 - 53). ICU mortality rate was 25%. Both SOFA score and serum lactate demonstrated a good prognostic value regarding ICU outcome (OR 1.29, 95%CI 1.07-1.57, P < 0.007 and OR 1.53, 95%CI 1.19-1.98, P < 0.001). A cut-off value for serum lactate of 6.55 mmol/L positively predicted mortality with 67% sensitivity and 97% specificity. Conclusion: NSTIs carry a high risk of septic shock and multiple organ dysfunction syndrome and thus are still associated with high mortality. In our study, the value of serum lactate at admission to the ICU correlated well with mortality. This easy-to-measure parameter could play a role in the decision-making process regarding prognosis and continuation of care.
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Affiliation(s)
- Alexandru Ogica
- Department of Intensive Care Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Christoph Burdelski
- Department of Intensive Care Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Holger Rohde
- Institute of Microbiology, Virology and Hygiene, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Stefan Kluge
- Department of Intensive Care Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Geraldine de Heer
- Department of Intensive Care Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
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John S, Riessen R, Karagiannidis C, Janssens U, Busch HJ, Kochanek M, Michels G, Hermes C, Buerke M, Kluge S, Baumgärtel M, Braune S, Erbguth F, Fuhrmann V, Lebiedz P, Mayer K, Müller-Werdan U, Oppert M, Sayk F, Sedding D, Willam C, Werdan K. [Core curriculum Medical intensive care medicine of the German Society of Medical Intensive Care and Emergency Medicine (DGIIN)]. Med Klin Intensivmed Notfmed 2021; 116:1-45. [PMID: 33427907 PMCID: PMC7799161 DOI: 10.1007/s00063-020-00765-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/26/2020] [Indexed: 11/25/2022]
Abstract
Medical intensive care medicine treats patients with severe, potentially life-threatening diseases covering the complete spectrum of internal medicine. The qualification in medical intensive care medicine requires a broad spectrum of knowledge and skills in medical intensive care medicine, but also in the general field of internal medicine. Both sides of the coin must be taken into account, the treatment with life-sustaining strategies of the acute illness of the patient and also the treatment of patient's underlying chronic diseases. The indispensable foundation of medical intensive care medicine as described in this curriculum includes basic knowledge and skills (level of competence I-III) as well as of behavior and attitudes. This curriculum is primarily dedicated to the internist in advanced training in medical intensive care medicine. However, this curriculum also intends to reach trainers in intensive care medicine and also the German physician chambers with their examiners, showing them which knowledge, skills as well as behavior and attitudes should be taught to trainees according to the education criteria of the German Society of Medical Intensive Care and Emergency Medicine (DGIIN).
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Affiliation(s)
- S John
- Klinikum Nürnberg-Süd, Medizinische Klinik 8, Abteilung für Internistische Intensivmedizin, Paracelsus Medizinische Privatuniversität, Nürnberg, Deutschland
| | - R Riessen
- Dept. für Innere Medizin, Internistische Intensivstation, Universitätsklinikum Tübingen, Tübingen, Deutschland
| | - C Karagiannidis
- ARDS und ECMO Zentrum Köln-Merheim, Professur für extrakorporale Lungenersatzverfahren der Universität Witten-Herdecke, Abteilung Pneumologie, Intensiv- und Beatmungsmedizin, Kliniken der Stadt Köln gGmbH, Köln, Deutschland
| | - U Janssens
- Klinik für Innere Medizin und Internistische Intensivmedizin, St.-Antonius-Hospital gGmbH, Akademisches Lehrkrankenhaus der RWTH Aachen, Eschweiler, Deutschland
| | - H-J Busch
- Universitäts-Notfallzentrum Freiburg, Universitätsklinikum Freiburg, Freiburg, Deutschland
| | - M Kochanek
- Klinik I für Innere Medizin (Hämatologie und Onkologie), Schwerpunkt Internistische Intensivmedizin, Universitätsklinikum Köln, Köln, Deutschland
| | - G Michels
- Klinik für Akut- und Notfallmedizin, St.-Antonius-Hospital gGmbH, Akademisches Lehrkrankenhaus der RWTH Aachen, Eschweiler, Deutschland
| | | | - M Buerke
- Medizinische Klinik II, St. Marien-Krankenhaus Siegen, Siegen, Deutschland
| | - S Kluge
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - M Baumgärtel
- Klinikum Nürnberg-Nord, Intensivstation 10/II, Klinik für Innere Medizin 3, Schwerpunkt Pneumologie, Paracelsus Medizinische Privatuniversität, Nürnberg, Deutschland
| | - S Braune
- IV. Med. Klinik - Internistische Intensivmedizin und Notaufnahme, Franziskus-Hospital Münster, Münster, Deutschland
| | - F Erbguth
- Klinikum Nürnberg, Universitätsklinik für Neurologie, Paracelsus Medizinische Privatuniversität, Nürnberg, Deutschland
| | - V Fuhrmann
- Klinik für Innere Medizin I, Evangelisches Klinikum Niederrhein, Duisburg, Deutschland
| | - P Lebiedz
- Klinik für Innere Medizin und Internistische Intensivmedizin, Ev. Krankenhaus Oldenburg, Steinweg 13-17, Oldenburg, Deutschland
| | - K Mayer
- Medizinische Klinik 4, Pneumologie und Schlafmedizin, ViDia Kliniken, Karlsruhe, Deutschland
| | - U Müller-Werdan
- Klinik für Geriatrie und Altersmedizin, Charité - Universitätsmedizin Berlin, Berlin, Deutschland
- Evangelisches Geriatriezentrum Berlin (EGZB), Berlin, Deutschland
| | - M Oppert
- Klinik für Notfall- und Intensivmedizin, Klinikum Ernst von Bergmann, Potsdam, Deutschland
| | - F Sayk
- Campus Lübeck, Medizinische Klinik I, Universitätsklinikum Schleswig-Holstein, Lübeck, Deutschland
| | - D Sedding
- Universitätsklinikum Halle (Saale), Klinik und Poliklinik für Innere Medizin III, Martin-Luther-Universität Halle-Wittenberg, Ernst-Grube-Straße 40, 06120, Halle (Saale), Deutschland
| | - C Willam
- Universitätsklinikum Erlangen, Medizinische Klinik 4, Nephrologie und Hypertensiologie, Friedrich-Alexander-Universität Erlangen, Erlangen, Deutschland
| | - K Werdan
- Universitätsklinikum Halle (Saale), Klinik und Poliklinik für Innere Medizin III, Martin-Luther-Universität Halle-Wittenberg, Ernst-Grube-Straße 40, 06120, Halle (Saale), Deutschland.
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38
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Spinner CD, Barton J, Biever P, Klein M, Rieg S, Schneider J, Thoden J, Wagner D, Kern WV. [Steroids in infection medicine]. Dtsch Med Wochenschr 2021; 146:162-166. [PMID: 33513649 DOI: 10.1055/a-1302-3530] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Corticosteroids have been found as useful adjunctive therapy in patients with various infections and hyperinflammation-associated disease. They are recommended in practice guidelines for patients with tuberculous and pneumococcal meningitis and patients with immune reconstitution syndrome associated with antiretroviral therapy. A new indication is severe COVID-19. Evidence from clinical trials is insufficient to allow the routine use of steroids among patients with septic shock, community-acquired pneumonia or tuberculous pericarditis.
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Affiliation(s)
- Christoph D Spinner
- Technische Universität München, Fakultät für Medizin, Klinikum rechts der Isar, Klinik und Poliklinik für Innere Medizin II, München
| | - Jürgen Barton
- Klinikum der Ludwig-Maximilians-Universität Klinikum, Medizinische Klinik und Poliklinik V, München
| | - Paul Biever
- Universitätsklinikum Freiburg, Abteilung Infektiologie, Klinik für Innere Medizin II, Freiburg.,Universitätsklinikum Freiburg, Klinik für Innere Medizin III, und Universitäts-Herzzentrum Freiburg - Bad Krozingen, Klinik für Kardiologie und Angiologie I, Freiburg
| | - Matthias Klein
- Klinikum der Ludwig-Maximilians-Universität Klinikum, Neurologische Klinik und Poliklinik, 81377 München
| | - Siegbert Rieg
- Universitätsklinikum Freiburg, Abteilung Infektiologie, Klinik für Innere Medizin II, Freiburg
| | - Jochen Schneider
- Technische Universität München, Fakultät für Medizin, Klinikum rechts der Isar, Klinik und Poliklinik für Innere Medizin II, München
| | - Jan Thoden
- Gemeinschaftspraxis Drs. Scholz/Thoden/Sandrock, Fachärzte für Innere Medizin, Rheumatologie, Infektiologie, Freiburg
| | - Dirk Wagner
- Universitätsklinikum Freiburg, Abteilung Infektiologie, Klinik für Innere Medizin II, Freiburg
| | - Winfried V Kern
- Universitätsklinikum Freiburg, Abteilung Infektiologie, Klinik für Innere Medizin II, Freiburg.,Albert-Ludwigs-Universität, Medizinische Fakultät, Freiburg
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39
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Fleischmann-Struzek C, Schwarzkopf D, Reinhart K. [Sepsis incidence in Germany and worldwide : Current knowledge and limitations of research using health claims data]. Med Klin Intensivmed Notfmed 2021; 117:264-268. [PMID: 33507316 PMCID: PMC7841759 DOI: 10.1007/s00063-021-00777-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 11/11/2020] [Accepted: 12/15/2020] [Indexed: 12/16/2022]
Abstract
Sepsis is the life-threatening organ dysfunction caused by a dysregulated host response to infection. With an estimated 48.9 million patients being affected by sepsis every year, sepsis is one of the most common diseases worldwide. Approximately 20% of global deaths are considered as sepsis-related. In Germany, a study based on nationwide hospital discharge data of almost all German hospitals found a sepsis incidence of 158 per 100,000 inhabitants. Estimates based on clinical patient data from other industrialized countries were 780/100,000 (Sweden) and 517/100,000 (USA). However, the comparability of incidence rates is limited due to the different data sources and sepsis case identification strategies used. In all, 41.7% of sepsis patients died in hospital, and 17.9% of intensive care unit patients are affected by sepsis. Case identification of sepsis in health claims data has a low sensitivity; therefore, it is likely that sepsis incidence is underestimated using these data, as many sepsis cases are not coded as such. For the purpose of epidemiological surveillance, health claims data should be complemented by other data sources such as registries or electronic health records.
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Affiliation(s)
- C Fleischmann-Struzek
- Center for Sepsis Control and Care, Universitätsklinikum Jena, Friedrich-Schiller-Universität Jena, Jena, Deutschland.,Institut für Infektionsmedizin und Krankenhaushygiene, Universitätsklinikum Jena, Friedrich-Schiller-Universität Jena, Jena, Deutschland
| | - D Schwarzkopf
- Center for Sepsis Control and Care, Universitätsklinikum Jena, Friedrich-Schiller-Universität Jena, Jena, Deutschland.,Institut für Infektionsmedizin und Krankenhaushygiene, Universitätsklinikum Jena, Friedrich-Schiller-Universität Jena, Jena, Deutschland
| | - K Reinhart
- Klinik für Anästhesiologie m. S. operative Intensivmedizin, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13357, Berlin, Deutschland.
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40
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Kluge S, Janssens U, Welte T, Weber-Carstens S, Schälte G, Spinner CD, Malin JJ, Gastmeier P, Langer F, Wepler M, Westhoff M, Pfeifer M, Rabe KF, Hoffmann F, Böttiger BW, Weinmann-Menke J, Kersten A, Berlit P, Haase R, Marx G, Karagiannidis C. [S2k Guideline - Recommendations for Inpatient Therapy of Patients with COVID-19]. Pneumologie 2021; 75:88-112. [PMID: 33450783 DOI: 10.1055/a-1334-1925] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Since December 2019, the novel coronavirus SARS-CoV-2 (Severe Acute Respiratory Syndrome - Corona Virus-2) has been spreading rapidly in the sense of a global pandemic. This poses significant challenges for clinicians and hospitals and is placing unprecedented strain on the healthcare systems of many countries. The majority of patients with Coronavirus Disease 2019 (COVID-19) present with only mild symptoms such as cough and fever. However, about 6 % require hospitalization. Early clarification of whether inpatient and, if necessary, intensive care treatment is medically appropriate and desired by the patient is of particular importance in the pandemic. Acute hypoxemic respiratory insufficiency with dyspnea and high respiratory rate (> 30/min) usually leads to admission to the intensive care unit. Often, bilateral pulmonary infiltrates/consolidations or even pulmonary emboli are already found on imaging. As the disease progresses, some of these patients develop acute respiratory distress syndrome (ARDS). Mortality reduction of available drug therapy in severe COVID-19 disease has only been demonstrated for dexamethasone in randomized controlled trials. The main goal of supportive therapy is to ensure adequate oxygenation. In this regard, invasive ventilation and repeated prone positioning are important elements in the treatment of severely hypoxemic COVID-19 patients. Strict adherence to basic hygiene, including hand hygiene, and the correct wearing of adequate personal protective equipment are essential when handling patients. Medically necessary actions on patients that could result in aerosol formation should be performed with extreme care and preparation.
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Affiliation(s)
- S Kluge
- Deutsche Gesellschaft für Internistische Intensivmedizin und Notfallmedizin (DGIIN); Berlin.,Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin (DIVI), Berlin.,Deutsche Gesellschaft für Pneumologie und Beatmungsmedizin (DGP), Berlin.,ARDS Netzwerk Deutschland, Berlin
| | - U Janssens
- Deutsche Gesellschaft für Internistische Intensivmedizin und Notfallmedizin (DGIIN); Berlin.,Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin (DIVI), Berlin.,ARDS Netzwerk Deutschland, Berlin
| | - T Welte
- Deutsche Gesellschaft für Internistische Intensivmedizin und Notfallmedizin (DGIIN); Berlin.,Deutsche Gesellschaft für Pneumologie und Beatmungsmedizin (DGP), Berlin.,ARDS Netzwerk Deutschland, Berlin
| | - S Weber-Carstens
- Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin (DIVI), Berlin.,Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI), Nürnberg.,ARDS Netzwerk Deutschland, Berlin
| | - G Schälte
- Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI), Nürnberg
| | - C D Spinner
- Deutsche Gesellschaft für Infektiologie (DGI), Berlin
| | - J J Malin
- Deutsche Gesellschaft für Infektiologie (DGI), Berlin
| | - P Gastmeier
- Deutsche Gesellschaft für Hygiene und Mikrobiologie (DGHM), Münster
| | - F Langer
- Gesellschaft für Thrombose und Hämostaseforschung (GTH), Köln
| | - M Wepler
- Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI), Nürnberg
| | - M Westhoff
- Deutsche Gesellschaft für Pneumologie und Beatmungsmedizin (DGP), Berlin
| | - M Pfeifer
- Deutsche Gesellschaft für Pneumologie und Beatmungsmedizin (DGP), Berlin
| | - K F Rabe
- Deutsche Gesellschaft für Pneumologie und Beatmungsmedizin (DGP), Berlin
| | - F Hoffmann
- Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin (DIVI), Berlin.,Deutsche Gesellschaft für Kinder- und Jugendmedizin (DGKJ), Berlin
| | - B W Böttiger
- Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin (DIVI), Berlin.,Deutscher Rat für Wiederbelebung (German Resuscitation Council; GRC), Ulm
| | | | - A Kersten
- Deutsche Gesellschaft für Kardiologie (DGK)
| | - P Berlit
- Deutsche Gesellschaft für Neurologie (DGN)
| | - R Haase
- Patientenvertretung (individueller Betroffener)
| | - G Marx
- Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin (DIVI), Berlin.,Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI), Nürnberg.,ARDS Netzwerk Deutschland, Berlin
| | - C Karagiannidis
- Deutsche Gesellschaft für Internistische Intensivmedizin und Notfallmedizin (DGIIN); Berlin.,Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin (DIVI), Berlin.,Deutsche Gesellschaft für Pneumologie und Beatmungsmedizin (DGP), Berlin.,ARDS Netzwerk Deutschland, Berlin
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41
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Wiedermann CJ. Phases of fluid management and the roles of human albumin solution in perioperative and critically ill patients. Curr Med Res Opin 2020; 36:1961-1973. [PMID: 33090028 DOI: 10.1080/03007995.2020.1840970] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Positive fluid balance is common among critically ill patients and leads to worse outcomes, particularly in sepsis, acute respiratory distress syndrome, and acute kidney injury. Restrictive fluid infusion and active removal of accumulated fluid are being studied as approaches to prevent and treat fluid overload. Use of human albumin solutions has been investigated in different phases of restrictive fluid resuscitation, and this narrative literature review was undertaken to evaluate hypoalbuminemia and the roles of human serum albumin with respect to hypovolemia and its management. METHODS PubMed/EMBASE search terms were: "resuscitation," "fluids," "fluid therapy," "fluid balance," "plasma volume," "colloids," "crystalloids," "albumin," "hypoalbuminemia," "starch," "saline," "balanced salt solution," "gelatin," "goal-directed therapy" (English-language, pre-January 2020). Additional papers were identified by manual searching of reference lists. RESULTS Restrictive fluid administration, plus early vasopressor use, may reduce fluid balance, but in some cases fluid overload cannot be entirely avoided. Deresuscitation, with fluid actively removed through diuretics or ultrafiltration, reduces duration of mechanical ventilation and intensive care unit stay. Combining hyperoncotic human albumin solution with diuretics increases hemodynamic stability and diuresis. Hyperoncotic albumin corrects hypoalbuminemia and raises colloid osmotic pressure, limiting edema formation and potentially improving endothelial function. Serum levels of albumin relative to C-reactive protein and lactate may predict which patients will benefit most from albumin therapy. CONCLUSIONS Hyperoncotic human albumin solution facilitates restrictive fluid therapy and the effectiveness of deresuscitative measures. Current evidence is mostly from observational studies, and more randomized trials are needed to better establish a personalized approach to fluid management.
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Affiliation(s)
- Christian J Wiedermann
- Institute of Public Health, Medical Decision Making and HTA, University of Health Sciences, Medical Informatics and Technology, Hall (Tyrol), Austria
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42
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Hennigs A, Jochum J. [Rational antimicrobial therapy - recommendations for common infections]. Dtsch Med Wochenschr 2020; 145:1673-1682. [PMID: 33202451 DOI: 10.1055/a-1114-3946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Infectious diseases are a frequent reason for medical consultations both in the inpatient and outpatient setting. Inadequate management is associated with increased costs, morbidity and mortality. In times of rising antibiotic resistance rational therapy and antimicrobial stewardship are of utmost importance. While it is crucial to avoid excessively broad antimicrobial coverage and unnecessary therapies, serious conditions must be treated effectively. The article highlights common infections and gives recommendations for empiric and targeted antibiotic treatment. Discussed are pulmonary, abdominal, urinary tract, skin and soft tissue infections, as well as sepsis and staphylococcal bloodstream infections. The recommendations consider national and international guidelines, recent publications and current antimicrobial resistance in Germany.
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43
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Stahl K, Seeliger B, David S, Schmidt J. [What is evidence-based in the treatment of sepsis?]. Internist (Berl) 2020; 61:1238-1248. [PMID: 33146751 DOI: 10.1007/s00108-020-00895-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The term sepsis was redefined in 2016 as a life-threatening organ dysfunction caused by an inadequate host response to an infection. The German S3 guidelines for the treatment of sepsis were published in 2018. OBJECTIVE What is evidence-based in the treatment of patients with sepsis? MATERIAL AND METHODS Discussion of the S3 guidelines and inclusion of study results after 2018. RESULTS The cornerstones for the treatment of sepsis continue to consist of early hemodynamic stabilization, anti-infection treatment and organ support procedures. Supportive and extracorporeal treatments are controversially discussed and continue to be intensively investigated. CONCLUSION Despite an improved understanding of the pathophysiology, there is still no effective causal sepsis treatment, i.e. directed against the pathological host reaction. The treatment of patients with sepsis is therefore still based on the basic principles of correction of volume deficits, anti-infective agents, source control and organ support, including the symptomatic treatment of vasoplegia with catecholamines.
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Affiliation(s)
- K Stahl
- Klinik für Gastroenterologie, Hepatologie und Endokrinologie, Medizinische Hochschule Hannover (MHH), Carl-Neuberg-Straße 1, 30625, Hannover, Deutschland.
| | - B Seeliger
- Klinik für Pneumologie, Medizinische Hochschule Hannover, Hannover, Deutschland
| | - S David
- Klinik für Nieren- und Hochdruckerkrankungen, Medizinische Hochschule Hannover, Hannover, Deutschland. .,Institut für Intensivmedizin, Universitätsspital Zürich, Rämistrasse 100, Zürich, Schweiz.
| | - J Schmidt
- Klinik für Nieren- und Hochdruckerkrankungen, Medizinische Hochschule Hannover, Hannover, Deutschland
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44
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Kluge S, Janssens U, Welte T, Weber-Carstens S, Schälte G, Salzberger B, Gastmeier P, Langer F, Wepler M, Westhoff M, Pfeifer M, Hoffmann F, Böttiger BW, Marx G, Karagiannidis C. [German recommendations for treatment of critically ill patients with COVID-19-version 3]. DER PNEUMOLOGE 2020; 17:406-425. [PMID: 33110402 PMCID: PMC7581953 DOI: 10.1007/s10405-020-00359-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/28/2023]
Abstract
Seit Dezember 2019 verbreitet sich das neuartige Coronavirus SARS-CoV‑2 (Severe Acute Respiratory Syndrome – Corona Virus-2) rasch im Sinne einer weltweiten Pandemie. Dies stellt Kliniker und Krankenhäuser vor große Herausforderungen und belastet die Gesundheitssysteme vieler Länder in einem nie dagewesenen Ausmaß. Die Mehrheit der Patienten zeigt lediglich milde Symptome der sogenannten Coronavirus Disease 2019 (COVID-19). Dennoch benötigen etwa 5–8 % eine intensivmedizinische Behandlung. Die akute hypoxämische respiratorische Insuffizienz mit Dyspnoe und hoher Atemfrequenz (>30/Min) führt in der Regel zur Aufnahme auf die Intensivstation. Oft finden sich dann bereits bilaterale pulmonale Infiltrate/Konsolidierungen oder auch Lungenembolien in der Bildgebung. Im weiteren Verlauf entwickeln viele Patienten ein Acute Respiratory Distress Syndrome (ARDS). Eine klinische Wirksamkeit einer medikamentösen Therapie bei schwerer COVID-Erkrankung (hospitalisierte Patienten) ist bisher für Remdesivir und Dexamethason nachgewiesen. Das Hauptziel der supportiven Therapie ist es eine ausreichende Oxygenierung sicherzustellen. Die invasive Beatmung und wiederholte Bauchlagerung sind dabei wichtige Elemente in der Behandlung von schwer hypoxämischen COVID-19 Patienten. Die strikte Einhaltung der Basishygiene, einschließlich der Händehygiene, sowie das korrekte Tragen von adäquater persönlicher Schutzausrüstung sind im Umgang mit den Patienten unabdingbar. Prozeduren, die zur Aerosolbildung führen könnten, sollten falls nötig, mit äußerster Sorgfalt und Vorbereitung durchgeführt werden.
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Affiliation(s)
- S. Kluge
- Deutsche Gesellschaft für Internistische Intensivmedizin und Notfallmedizin (DGIIN), Berlin, Deutschland
- Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin (DIVI), Berlin, Deutschland
- Deutsche Gesellschaft für Pneumologie und Beatmungsmedizin (DGP), Berlin, Deutschland
- ARDS Netzwerk Deutschland, Berlin, Deutschland
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Deutschland
| | - U. Janssens
- Deutsche Gesellschaft für Internistische Intensivmedizin und Notfallmedizin (DGIIN), Berlin, Deutschland
- Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin (DIVI), Berlin, Deutschland
- ARDS Netzwerk Deutschland, Berlin, Deutschland
| | - T. Welte
- Deutsche Gesellschaft für Internistische Intensivmedizin und Notfallmedizin (DGIIN), Berlin, Deutschland
- Deutsche Gesellschaft für Pneumologie und Beatmungsmedizin (DGP), Berlin, Deutschland
- ARDS Netzwerk Deutschland, Berlin, Deutschland
| | - S. Weber-Carstens
- Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin (DIVI), Berlin, Deutschland
- Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI), Nürnberg, Deutschland
- ARDS Netzwerk Deutschland, Berlin, Deutschland
| | - G. Schälte
- Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI), Nürnberg, Deutschland
| | - B. Salzberger
- Deutsche Gesellschaft für Infektiologie (DGI), München, Deutschland
| | - P. Gastmeier
- Deutsche Gesellschaft für Hygiene und Mikrobiologie (DGHM), Münster, Deutschland
| | - F. Langer
- Gesellschaft für Thrombose und Hämostaseforschung (GTH), Köln, Deutschland
| | - M. Wepler
- Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI), Nürnberg, Deutschland
| | - M. Westhoff
- Deutsche Gesellschaft für Pneumologie und Beatmungsmedizin (DGP), Berlin, Deutschland
| | - M. Pfeifer
- Deutsche Gesellschaft für Pneumologie und Beatmungsmedizin (DGP), Berlin, Deutschland
| | - F. Hoffmann
- Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin (DIVI), Berlin, Deutschland
- Deutsche Gesellschaft für Kinder- und Jugendmedizin (DGKJ), Berlin, Deutschland
| | - B. W. Böttiger
- Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin (DIVI), Berlin, Deutschland
- Deutscher Rat für Wiederbelebung (German Resuscitation Council; GRC), Ulm, Deutschland
| | - G. Marx
- Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin (DIVI), Berlin, Deutschland
- Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI), Nürnberg, Deutschland
- ARDS Netzwerk Deutschland, Berlin, Deutschland
| | - C. Karagiannidis
- Deutsche Gesellschaft für Internistische Intensivmedizin und Notfallmedizin (DGIIN), Berlin, Deutschland
- Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin (DIVI), Berlin, Deutschland
- Deutsche Gesellschaft für Pneumologie und Beatmungsmedizin (DGP), Berlin, Deutschland
- ARDS Netzwerk Deutschland, Berlin, Deutschland
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45
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Edel A, Reinhart K, Schaller SJ. [Critical statement on selected recommendations of the new German S3 Sepsis Guideline]. Med Klin Intensivmed Notfmed 2020; 115:505-507. [PMID: 32910285 PMCID: PMC7481338 DOI: 10.1007/s00063-020-00720-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Andreas Edel
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin (CVK/CCM), Charitéplatz 1, Berlin, Deutschland
| | - Konrad Reinhart
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin (CVK/CCM), Charitéplatz 1, Berlin, Deutschland
| | - Stefan J Schaller
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin (CVK/CCM), Charitéplatz 1, Berlin, Deutschland.
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46
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Kluge S, Janssens U, Welte T, Weber-Carstens S, Schälte G, Salzberger B, Gastmeier P, Langer F, Wepler M, Westhoff M, Pfeifer M, Hoffmann F, Böttiger BW, Marx G, Karagiannidis C. [German recommendations for treatment of critically ill patients with COVID-19-version 3 : S1-guideline]. Anaesthesist 2020; 69:653-664. [PMID: 32833080 PMCID: PMC7444177 DOI: 10.1007/s00101-020-00833-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Seit Dezember 2019 verbreitet sich das neuartige Coronavirus SARS-CoV‑2 (Severe Acute Respiratory Syndrome – Corona Virus-2) rasch im Sinne einer weltweiten Pandemie. Dies stellt Kliniker und Krankenhäuser vor große Herausforderungen und belastet die Gesundheitssysteme vieler Länder in einem nie dagewesenen Ausmaß. Die Mehrheit der Patienten zeigt lediglich milde Symptome der sogenannten Coronavirus Disease 2019 (COVID-19). Dennoch benötigen etwa 5–8 % eine intensivmedizinische Behandlung. Die akute hypoxämische respiratorische Insuffizienz mit Dyspnoe und hoher Atemfrequenz (>30/Min) führt in der Regel zur Aufnahme auf die Intensivstation. Oft finden sich dann bereits bilaterale pulmonale Infiltrate/Konsolidierungen oder auch Lungenembolien in der Bildgebung. Im weiteren Verlauf entwickeln viele Patienten ein Acute Respiratory Distress Syndrome (ARDS). Eine klinische Wirksamkeit einer medikamentösen Therapie bei schwerer COVID-Erkrankung (hospitalisierte Patienten) ist bisher für Remdesivir und Dexamethason nachgewiesen. Das Hauptziel der supportiven Therapie ist es eine ausreichende Oxygenierung sicherzustellen. Die invasive Beatmung und wiederholte Bauchlagerung sind dabei wichtige Elemente in der Behandlung von schwer hypoxämischen COVID-19 Patienten. Die strikte Einhaltung der Basishygiene, einschließlich der Händehygiene, sowie das korrekte Tragen von adäquater persönlicher Schutzausrüstung sind im Umgang mit den Patienten unabdingbar. Prozeduren, die zur Aerosolbildung führen könnten, sollten falls nötig, mit äußerster Sorgfalt und Vorbereitung durchgeführt werden.
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Affiliation(s)
- S Kluge
- Deutsche Gesellschaft für Internistische Intensivmedizin und Notfallmedizin (DGIIN), Berlin, Deutschland.
- Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin (DIVI), Berlin, Deutschland.
- Deutsche Gesellschaft für Pneumologie und Beatmungsmedizin (DGP), Berlin, Deutschland.
- ARDS Netzwerk Deutschland, Berlin, Deutschland.
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Deutschland.
| | - U Janssens
- Deutsche Gesellschaft für Internistische Intensivmedizin und Notfallmedizin (DGIIN), Berlin, Deutschland
- Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin (DIVI), Berlin, Deutschland
- ARDS Netzwerk Deutschland, Berlin, Deutschland
| | - T Welte
- Deutsche Gesellschaft für Internistische Intensivmedizin und Notfallmedizin (DGIIN), Berlin, Deutschland
- Deutsche Gesellschaft für Pneumologie und Beatmungsmedizin (DGP), Berlin, Deutschland
- ARDS Netzwerk Deutschland, Berlin, Deutschland
| | - S Weber-Carstens
- Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin (DIVI), Berlin, Deutschland
- Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI), Nürnberg, Deutschland
- ARDS Netzwerk Deutschland, Berlin, Deutschland
| | - G Schälte
- Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI), Nürnberg, Deutschland
| | - B Salzberger
- Deutsche Gesellschaft für Infektiologie (DGI), München, Deutschland
| | - P Gastmeier
- Deutsche Gesellschaft für Hygiene und Mikrobiologie (DGHM), Münster, Deutschland
| | - F Langer
- Gesellschaft für Thrombose und Hämostaseforschung (GTH), Köln, Deutschland
| | - M Wepler
- Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI), Nürnberg, Deutschland
| | - M Westhoff
- Deutsche Gesellschaft für Pneumologie und Beatmungsmedizin (DGP), Berlin, Deutschland
| | - M Pfeifer
- Deutsche Gesellschaft für Pneumologie und Beatmungsmedizin (DGP), Berlin, Deutschland
| | - F Hoffmann
- Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin (DIVI), Berlin, Deutschland
- Deutsche Gesellschaft für Kinder- und Jugendmedizin (DGKJ), Berlin, Deutschland
| | - B W Böttiger
- Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin (DIVI), Berlin, Deutschland
- Deutscher Rat für Wiederbelebung (German Resuscitation Council; GRC), Ulm, Deutschland
| | - G Marx
- Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin (DIVI), Berlin, Deutschland
- Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI), Nürnberg, Deutschland
- ARDS Netzwerk Deutschland, Berlin, Deutschland
| | - C Karagiannidis
- Deutsche Gesellschaft für Internistische Intensivmedizin und Notfallmedizin (DGIIN), Berlin, Deutschland
- Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin (DIVI), Berlin, Deutschland
- Deutsche Gesellschaft für Pneumologie und Beatmungsmedizin (DGP), Berlin, Deutschland
- ARDS Netzwerk Deutschland, Berlin, Deutschland
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Hanses F. [Anti-infective treatment : Treatment strategies for sepsis and septic shock]. Internist (Berl) 2020; 61:1002-1009. [PMID: 32865593 DOI: 10.1007/s00108-020-00855-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Sepsis and septic shock are still associated with a high mortality and morbidity. A decisive factor for improvement of the outcome is the prompt initiation of an effective antibiotic treatment. The early recognition of sepsis within the first hour is here one of the biggest challenges. Effective empirical treatment comprises purposefully selected broad-spectrum antibiotics and also combination treatment or antimycotics in special situations. De-escalation strategies to narrow down or shorten the treatment are safe and can limit the side effects.
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Affiliation(s)
- Frank Hanses
- Interdisziplinäre Notaufnahme und Abteilung für Krankenhaushygiene und Infektiologie, Universitätsklinikum Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Deutschland.
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