Intraoperative haemodynamic monitoring and management of adults having non-cardiac surgery: Guidelines of the German Society of Anaesthesiology and Intensive Care Medicine in collaboration with the German Association of the Scientific Medical Societies

Haemodynamic monitoring and management are cornerstones of perioperative care. The goal of haemodynamic management is to maintain organ function by ensuring adequate perfusion pressure, blood flow, and oxygen delivery. We here present guidelines on "Intraoperative haemodynamic monitoring and management of adults having non-cardiac surgery" that were prepared by 18 experts on behalf of the German Society of Anaesthesiology and Intensive Care Medicine (Deutsche Gesellschaft für Anästhesiologie und lntensivmedizin; DGAI).

Serum concentration of continuously administered vancomycin influences efficacy and safety in critically ill adults: a systematic review

OBJECTIVES

Vancomycin is used to treat Gram-positive infections in critically ill adults. For vancomycin administered by continuous infusion (CI), various target ranges have been used, ranging from 15-20 mg/L to 30-40 mg/L. This systematic literature review was conducted to investigate the impact of steady-state serum concentration (Css) of CI on safety and efficacy of therapy in critically ill adults.

METHODS

Relevant literature was identified by searching two electronic databases (PubMed, Cochrane Library) and Google Scholar from inception until July 2023, focusing on studies reporting measured Css and treatment outcomes (e.g. mortality, nephrotoxicity) with CI. Due to study heterogeneity, a narrative synthesis of the evidence was performed.

RESULTS

Twenty-one publications were included with a total of 2949 patients. Mortality was higher (two studies, n = 388 patients) and clinical cure was lower (one study, n = 40 patients) with Css < 15 mg/L measured 24 h after initiation of CI (C24). An adequate loading dose appeared most important for maintaining higher C24. Generally, higher Css was associated with higher rates of acute kidney injury (AKI) (15 studies, n = 2331 patients). It was calculated that Css < 25 mg/L (versus ≥25 mg/L) was preferable for reducing nephrotoxicity (three studies, n = 515 patients).

CONCLUSIONS

Despite sparse data availability, the target range of 15-25 mg/L in CI may increase clinical cure and reduce mortality and AKI. In future research, vancomycin Css cohorts should be formed to allow evaluation of the impact of Css of CI on treatment outcomes.

A case of recurring perioperative circulatory arrest: mind the autonomic nervous system

We report the case of an elderly woman who developed recurring episodes of unexplained cardiocirculatory arrest. The index event appeared during surgery to fix a fracture of the ankle and consisted of bradypnea, hypotension and asystole, coherent with a Bezold-Jarisch-like cardioprotective reflex. Classical signs of acute myocardial infarction were absent. Yet, occlusion of the right coronary artery (RCA) was observed and successfully revascularized, whereupon circulatory arrests vanished. We discuss several differential diagnoses. Unexplainable circulatory failure, with sinus bradycardia and arterial hypotension, despite lack of ECG signs of ischemia or significant troponin levels, suggest the action of cardioprotective reflexes of the autonomic nervous system. Coronary artery disease is a common source. Attention to cardioprotective reflexes should be taken in the case of unexplained cardiac arrest without overt reasons. We recommend performing coronary angiography to exclude significant coronary stenosis.

[Peripartum hemorrhage, diagnostics and treatment : Update of the S2k guidelines AWMF 015/063 from August 2022]

The current S2k guidelines on the diagnostics and treatment of peripartum hemorrhage are summarized in this article from the perspective of anesthesiology based on a fictitious case report. The update of the guidelines was written under the auspices of the German Society of Gynecology and Obstetrics with the participation of other professional societies and interest groups from Germany, Austria and Switzerland and published by the AWMF in 2022 under the register number 015/063.

Microvascular perfusion, perfused boundary region and glycocalyx shedding in patients with autosomal dominant polycystic kidney disease: results from the GlycoScore III study

Background

Vascular abnormalities and endothelial dysfunction are part of the spectrum of autosomal dominant polycystic kidney disease (ADPKD). The mechanisms behind these manifestations, including potential effects on the endothelial surface layer (ESL) and glycocalyx integrity, remain unknown.

Methods

Forty-five ambulatory adult patients with ADPKD were enrolled in this prospective, observational, cross-sectional, single-centre study. Fifty-one healthy volunteers served as a control group. All participants underwent real-time microvascular perfusion measurements of the sublingual microcirculation using sidestream dark field imaging. After image acquisition, the perfused boundary region (PBR), an inverse parameter for red blood cell (RBC) penetration into the ESL, was automatically calculated. Microvascular perfusion was assessed by RBC filling and capillary density. Concentrations of circulating glycocalyx components were determined by enzyme-linked immunosorbent assay.

Results

ADPKD patients showed a significantly larger PBR compared with healthy controls (2.09 ± 0.23 µm versus 1.79 ± 0.25 µm; P < .001). This was accompanied by significantly lower RBC filling (70.4 ± 5.0% versus 77.9 ± 5.4%; P < .001) as well as a higher valid capillary density {318/mm² [interquartile range (IQR) 269-380] versus 273/mm² [230-327]; P = .007}. Significantly higher plasma concentrations of heparan sulphate (1625 ± 807 ng/ml versus 1329 ± 316 ng/ml; P = .034), hyaluronan (111 ng/ml [IQR 79-132] versus 92 ng/ml [82-98]; P = .042) and syndecan-1 were noted in ADPKD patients compared with healthy controls (35 ng/ml [IQR 27-57] versus 29 ng/ml [23-42]; P = .035).

Conclusions

Dimensions and integrity of the ESL are impaired in ADPKD patients. Increased capillary density may be a compensatory mechanism for vascular dysfunction to ensure sufficient tissue perfusion and oxygenation.

The influence of orthopedic surgery on the incidence of post-operative delirium in geriatric patients: results of a prospective observational study

Background

Postoperative delirium (PD) is a major concern in geriatric patients undergoing orthopedic surgery. This prospective observational study aims to examine the incidence of PD, to identify intervention-specific risk factors and to investigate the influence of orthopedic surgery on delirium.

Methods

From 2019 to 2020, 132 patients ≥70 years of age with endoprosthetic (Group E) or spinal surgery (Group S) were included. Upon admission, the ISAR score, the Nursing Delirium Screening Scale, potential risk factors, the ASA score, duration of surgery, type of anesthesia, blood loss, and hemoglobin drop were recorded. For risk factor analysis patients were grouped into Group D (delirium) and Group ND (no delirium). Primary endpoint was the occurrence of PD.

Results

Of 132 patients, 50 were included in Group E and 82 in Group S. Mean age and ISAR score were not significantly different between groups. Delirium rate in Group E and S was 12% vs. 18% (p = 0.3). Differences could be observed between Group D and ND in duration of surgery (173 min vs. 112 min, p = 0.02), postoperative hemoglobin drop (3.2 g/dl vs. 2.3 g/dl; p = 0.026), history of PD (23% vs. 11%, p = 0.039) and use of isoflurane (6 vs. 2). Type of surgery was not an independent risk factor (p = 0.26).

Conclusion

Specific type of orthopedic surgery is not an independent risk factor for PD. Prevention of PD should focus on duration of surgery and blood loss, particularly in patients with a history of PD. A possible delirogenic potential of isoflurane should be further studied.

Shedding of the Endothelial Glycocalyx Independent of Systemic Tryptase Release during Oncologic Oral Surgery: An Observational Study

The endothelial glycocalyx and endothelial surface layer are crucial for several functions of the vasculature. Damage to the glycocalyx (“shedding”) occurs during diverse clinical conditions, including major surgery. Mast cell tryptase has been proposed as one possible “sheddase”. During oncologic oral surgery, glycocalyx shedding could be detrimental due to loss of vascular barrier function and consequent oedema in the musculocutaneous flap graft. Concentrations of the glycocalyx components heparan sulphate and syndecan-1, as well as of tryptase in blood serum before and after surgery, were measured in 16 patients undergoing oncologic oral surgery. Secondary measures were the concentrations of these substances on postoperative days 1 and 2. Heparan sulphate rose from 692 (median, interquartile range: 535–845) to 810 (638–963) ng/mL during surgery. Syndecan-1 increased from 35 (22–77) ng/mL to 138 (71–192) ng/mL. Tryptase remained virtually unchanged with 4.2 (3–5.6) before and 4.2 (2.5–5.5) ng/mL after surgery. Concentrations of heparan sulphate and syndecan-1 in serum increased during surgery, indicating glycocalyx shedding. Tryptase concentration remained equal, suggesting other sheddases than systemic tryptase release to be responsible for damage to the glycocalyx. Investigating strategies to protect the glycocalyx during oncologic oral surgery might hold potential to improve flap viability and patient outcome.

[Prioritization of intensive medical treatment places - Concept proposal]

In the situation of a shortage of ventilation beds, ethically justifiable, transparent and comprehensible decisions must be made. This concept proposes that all patients are first intubated depending on necessity and then assessed by a triage team afterwards. In this situation newly admitted COVID patients compete with newly admitted Non-COVID patients as well as patients already treated in intensive care units for a ventilator. The combination of short-term and long-term prognoses should enable the interprofessional triage team to make comprehensible decisions. The aim of the prioritization concept is to save as many human lives as possible and to relieve the treatment team of the difficult decision on prioritization.

[Perioperative enhanced recovery after surgery program for Ivor Lewis esophagectomy : First experiences of a high-volume center]

BACKGROUND AND OBJECTIVE

Transthoracic esophagectomy is generally accepted as the standard of surgical care for patients with esophageal cancer. Despite improvements in the perioperative management this surgical procedure is associated with a clinically relevant morbidity. Fast-track protocols (synonym: enhanced recovery after surgery, ERAS) are conceived to perioperatively maintain the physiological homoeostasis and thereby to accelerate postoperative rehabilitation and reduce morbidity. In this prospective observational study the initial experiences of a high-volume center with the implementation of an ERAS protocol after transthoracic esophagectomy were analyzed.

MATERIAL AND METHODS

A total of 26 patients with esophageal cancer and a low index of comorbidities prior to hybrid Ivor Lewis esophagectomy were included in this study. According to an ERAS protocol all patients underwent a standardized perioperative treatment pathway aiming to discharge the patients from the inpatient treatment on postoperative day 10. The primary outcome parameter was the rate of major complications (Clavien-Dindo IIIb/IV), which was compared to a cohort of 52 non-ERAS patients.

RESULTS AND CONCLUSION

The ERAS programs with the various core elements can be implemented in patients scheduled for transthoracic esophagectomy, although the organizational and personnel expenditure of this fast-track protocol is high. The length of hospital stay appears to be reduced without compromising patient safety. The limiting variable of the ERAS protocol remains the early and adequate enteral feeding load of the gastric conduit before discharge on postoperative day 10.

Effects of a single aerobic exercise on perfused boundary region and microvascular perfusion: a field study

The endothelium and the glycocalyx play a pivotal role in regulating microvascular function and perfusion in health and critical illness. It is unknown today, whether aerobic exercise immediately affects dimensions of the endothelial surface layer (ESL) in relation to microvascular perfusion as a physiologic adaption to increased nutritional demands. This monocentric observational study was designed to determine real-time ESL and perfusion measurements of the sublingual microcirculation using sidestream dark field imaging performed in 14 healthy subjects before and after completing a 10 km trial running distance. A novel image acquisition and analysis software automatically analysed the perfused boundary region (PBR), an inverse parameter for red blood cell (RBC) penetration of the ESL, in vessels between 5 and 25 µm diameter. Microvascular perfusion was assessed by calculating RBC filling percentage. There was no significant immediate effect of exercise on PBR and RBC filling percentage. Linear regression analysis revealed a distinct association between change of PBR and change of RBC filling percentage (regression coefficient β: − 0.026; 95% confidence interval − 0.043 to − 0.009; p = 0.006). A single aerobic exercise did not induce a change of PBR or RBC filling percentage. The endothelium of the microvasculature facilitates efficient perfusion in vessels reacting with an increased endothelial surface layer.

[Acute treatment of pregnant women after severe trauma-a retrospective multicenter analysis]

BACKGROUND

For the medical team, the management of pregnant trauma patients is a particular challenge. The aim of this study is to compile this data and to determine differences between pregnant and not pregnant trauma patients.

MATERIALS AND METHODS

We carried out a retrospective data analysis from the TraumaRegister DGU® with a comparison of 102 pregnant and 3135 not pregnant women of child-bearing age (16-45 years) from 2016-2018 who were treated in a trauma center. All patients were delivered to the resuscitation room and received intensive care treatment.

RESULTS

In Germany, Austria and Switzerland 3.2% of all trauma patients (102 women) were pregnant. Women with an average age of 29 years suffered most often trauma as a result of a road traffic accident. Major trauma (Injury Severity Score [ISS] ≥16 points) was seen in 24.5% of the pregnant women and 37.4% of the nonpregnant women. A computer tomography (whole body computer tomography) was carried out in 32.7% of all pregnant women but in 79.8% of the nonpregnant women. As a result of the trauma, 2.9% of the pregnant and 3.5% of the not pregnant women died. The standardised mortality rate (SMR) was 0.42 in pregnant women and 0.63 in nonpregnant women.

CONCLUSION

For the first time there is data regarding incidence, trauma mechanism, prehospital and in-hospital care as well as intensive care of pregnant trauma patients in Germany, Austria and Switzerland. Further research regarding foetal outcome and trauma-related injuries in pregnant women is needed to develop an adjusted management for these patients ready to implement in trauma centres. Gynaecologists and obstetricians should be implemented in the trauma room team when needed.

Hemoadsorption: effective in reducing circulating fragments of the endothelial glycocalyx during cardiopulmonary bypass in patients undergoing on-pump cardiac surgery?

BACKGROUND

The vascular endothelial glycocalyx is susceptible to ischemia and hypoxia. Released soluble components of the endothelial glycocalyx (EG) have been identified as potential damage associated molecular patterns (DAMPs) able to enhance an ongoing inflammatory response. Shedding of the EG has been associated with released atrial-natriuretic peptide (ANP) during cardiac surgery procedures. A novel hemoadsorption technique (CytoSorb^®) has been shown to effectively remove molecules up to 55 kDa unspecifically from circulation. It is not known whether ANP or glycocalyx components can be removed successfully by this technique.

METHODS

In 15 patients undergoing on-pump cardiac surgery, the hemoadsorption device was integrated in the cardiopulmonary bypass (CPB) circuit. Pre- and post-adsorber concentrations of ANP, heparan sulphate (HEP), syndecan-1 (SYN) and hyaluronan (HYA) were measured at 10 (T1), 30 (T2), and 60 (T3) minutes after aortic cross-clamping and complete CPB.

RESULTS

Hemoadsorption significantly reduced mean HEP concentrations (-157.5 [333.4] ng/mL; P<0.001) post adsorber. For ANP and SYN no statistically significant changes were detected whereas mean [SD] HYA concentrations even increased significantly (+21.6 [43.0] ng/mL; P<0.001) post adsorber.

CONCLUSIONS

In this study representing a real-life scenario, we could demonstrate that the novel hemoadsorption device (CytoSorb^®) was able to effectively adsorb HEP from the circulation if integrated in a CPB circuit. However, blood concentrations of HYA, SYN, and ANP could not be reduced during CPB in our investigation.

Feasibility study of MR-guided pancreas ablation using high-intensity focused ultrasound in a healthy swine model

Purpose: Pancreatic cancer is typically diagnosed in a late stage with limited therapeutic options. For those patients, ultrasound-guided high-intensity focused ultrasound (US-HIFU) can improve local control and alleviate pain. However, MRI-guided HIFU (MR-HIFU) has not yet been studied extensively in this context. To facilitate related research and accelerate clinical translation, we report a workflow for the in vivo HIFU ablation of the porcine pancreas under MRI guidance.Materials and methods: The pancreases of five healthy German landrace pigs (35-58 kg) were sonicated using a clinical MR-HIFU system. Acoustic access to the pancreas was supported by a specialized diet and a hydrogel compression device for bowel displacement. Organ motion was suspended using periods of apnea. The size of the resulting thermal lesions was assessed using the thermal threshold- and dose profiles, non-perfused volume, and gross examination. The effect of the compression device on beam path length was assessed using MRI imaging.Results: Eight of ten treatments resulted in clearly visible damage in the target tissue upon gross examination. Five treatments resulted in coagulative necrosis. Good agreement between the four metrics for lesion size and a clear correlation between the delivered energy dose and the resulting lesion size were found. The compression device notably shortened the intra-abdominal beam path.Conclusions: We demonstrated a workflow for HIFU treatment of the porcine pancreas in-vivo under MRI-guidance. This development bears significance for the development of MR-guided HIFU interventions on the pancreas as the pig is the preferred animal model for the translation of pre-clinical research into clinical application.

First-time evaluation of ascending compared to rectangular transthoracic defibrillation waveforms in modelled out-of-hospital cardiac arrest

Aim of the study

Prognosis in out-of-hospital cardiac arrest (OHCA) depends on cardiopulmonary resuscitation (CPR) duration. Therefore, the optimal biphasic defibrillation waveform shows high conversion rates besides low energy. Matthew Fishler theoretically predicted it to be truncated ascending exponential. We realised a prototypic defibrillator and compared ascending with conventional rectangular waveforms in modelled OHCA and CPR.

Methods

Approved by the authorities, 57 healthy swine (Landrace ​× ​Piétrain) were randomised to ASCDefib (n 26) or CONVDefib (n 26). Five swine served as sham control. We induced ventricular fibrillation (VF) electrically in anaesthetised swine randomised to ASCDefib or CONVDefib and discontinued mechanical ventilation. After 5 ​min of untreated cardiac arrest, we started CPR with mechanical chest compressions and ventilation. We performed transthoracic biphasic defibrillations after 2, 4, 6 and 8 ​min CPR targeting 4 ​J/kg in either group. Depending on the randomised group, the defibrillation protocol was either three ascending followed by one rectangular waveform (ASCDefib) or three rectangular followed by one ascending waveform (CONVDefib).

Results

Under our model-specific conditions, VF was initially terminated by 13/80 ascending waveforms and 13/79 rectangular waveforms and persistent return of spontaneous circulation was achieved in 8/26 (ASCDefib) vs. 10/26 (CONVDefib) animals. Mean current rather than waveform design was predictive for defibrillation success in a generalised linear model.

Conclusion

Contrary to theoretical assumptions, transthoracic biphasic defibrillation with ascending waveforms is not superior to rectangular waveforms in modelled OHCA. We advocate defibrillation dosage to be guided by current, that has proven its predictive value again.

Institutional protocol number

84–02.04.2017.A176.

Intravascular Cooling Device Versus Esophageal Heat Exchanger for Mild Therapeutic Hypothermia in an Experimental Setting

BACKGROUND

Targeted temperature management is a standard therapy for unconscious survivors of cardiac arrest. To date, multiple cooling methods are available including invasive intravascular cooling devices (IVDs), which are widely used in the clinical setting. Recently, esophageal heat exchangers (EHEs) have been developed providing cooling via the esophagus that is located close to the aorta and inferior vena cava. The objective was to compare mean cooling rates, as well as differences, to target temperature during maintenance and the rewarming period of IVD and EHE.

METHODS

The study was conducted in 16 female domestic pigs. After randomization to either IVD or EHE (n = 8/group), core body temperature was reduced to 33°C. After 24 hours of maintenance (33°C), animals were rewarmed using a target rate of 0.25°C/h for 10 hours. All cooling phases were steered by a closed-loop feedback system between the internal jugular vein and the chiller. After euthanasia, laryngeal and esophageal tissue was harvested for histopathological examination.

RESULTS

Mean cooling rates (4.0°C/h ± 0.4°C/h for IVD and 2.4°C/h ± 0.3°C/h for EHE; P < .0008) and time to target temperature (85.1 ± 9.2 minutes for IVD and 142.0 ± 21.2 minutes for EHE; P = .0008) were different. Mean difference to target temperature during maintenance (0.07°C ± 0.05°C for IVD and 0.08°C ± 0.10°C for EHE; P = .496) and mean rewarming rates (0.2°C/h ± 0.1°C/h for IVD and 0.3°C/h ± 0.2°C/h for EHE; P = .226) were similar. Relevant laryngeal or esophageal tissue damage could not be detected. There were no significant differences in undesired side effects (eg, bradycardia or tachycardia, hypokalemia or hyperkalemia, hypoglycemia or hyperglycemia, hypotension, overcooling, or shivering).

CONCLUSIONS

After insertion, target temperatures could be reached faster by IVD compared to EHE. Cooling performance of IVD and EHE did not significantly differ in maintaining target temperature during a targeted temperature management process and in active rewarming protocols according to intensive care unit guidelines in this experimental setting.

Rescue under ongoing CPR from an upper floor: evaluation of three different evacuation routes and mechanical and manual chest compressions: a manikin trial

BACKGROUND

If transport under ongoing cardiopulmonary resuscitation (CPR) from an upper floor is indicated, the ideal CPR-method and evacuation route is unknown hitherto. We aimed to elaborate a strategy for evacuation of patients under ongoing CPR from an upper floor, comparing three different evacuation routes and manual and mechanical chest compressions.

METHODS

A CPR-training manikin recording CPR-quality was placed on the fifth floor and was evacuated to an ambulance via lift, turntable ladder, or staircase. Chest compressions were performed manually or with a mechanical CPR-device. Efficiency endpoints were compression depth and frequency, sufficiency of chest release, compared with European Resuscitation Council (ERC) Guidelines, and duration of the evacuation. Adverse outcomes were disconnection/dislocation of devices and hazards/accidents to the personnel.

RESULTS

For all evacuation routes, compression depth and frequency were significantly more compliant with ERC-guidelines under mechanical CPR. Manual CPR was associated with considerable deviations from correct compression depth and frequency. Chest release only slightly differed between groups. Evacuation via lift under mechanical CPR was fastest and evacuation via turntable ladder under manual CPR was slowest. No device disconnections or accidents occurred, but hazard to personnel was perceived during evacuation via ladder under manual CPR.

CONCLUSIONS

In this study, a mechanical CPR-device proved to deliver better CPR-quality during evacuation from an upper floor. If a lift accessible with a stretcher is available, this route should be preferred, regardless of manual or mechanical CPR. Turntable ladders can only be meaningfully used with mechanical CPR, otherwise CPR-quality is poor and hazard to the personnel is increased. Not all evacuation routes may be useable in a specific real-life scenario.

TRIAL REGISTRATION

German Clinical Trials Registry, www.drks.de, registration number DRKS00012885, registration date 17.08.2017.

[Selection of the optimal anesthesia regimen for cesarean section]

Approximately one third of all children in Germany are delivered by cesarean section. Depending on the individual patient's condition and the situation, the anesthesiologist has to choose between a general or a regional anesthesia regimen. The decisive factor for the selection is the obstetric urgency (decision-delivery time) after ascertainment of the indications. Furthermore, the need for postoperative analgesia varies depending on the chosen anesthesia regimen.

Intra-patient potassium variability after hypothermic cardiac arrest: a multicentre, prospective study

Background

To date, the decision to set up therapeutic extra-corporeal life support (ECLS) in hypothermia-related cardiac arrest is based on the potassium value only. However, no information is available about how the analysis should be performed. Our goal was to compare intra-individual variation in serum potassium values depending on the sampling site and analytical technique in hypothermia-related cardiac arrests.

Methods

Adult patients with suspected hypothermia-related refractory cardiac arrest, admitted to three hospitals with ECLS facilities were included. Blood samples were obtained from the femoral vein, a peripheral vein and the femoral artery. Serum potassium was analysed using blood gas (BGA) and clinical laboratory analysis (CL).

Results

Of the 15 consecutive patients included, 12 met the principal criteria, and 5 (33%) survived. The difference in average potassium values between sites or analytical method used was ≤1 mmol/L. The agreement between potassium values according to the three different sampling sites was poor. The ranges of the differences in potassium using BGA measurement were − 1.6 to + 1.7 mmol/L; − 1.18 to + 2.7 mmol/L and − 0.87 to + 2 mmol/L when comparing respectively central venous and peripheral venous, central venous and arterial, and peripheral venous and arterial potassium.

Conclusions

We found important and clinically relevant variability in potassium values between sampling sites. Clinical decisions should not rely on one biological indicator. However, according to our results, the site of lowest potassium, and therefore the preferred site for a single potassium sampling is central venous blood. The use of multivariable prediction tools may help to mitigate the risks inherent in the limits of potassium measurement.

Trial registration

ClinicalTrials.gov Identifier: NCT03096561.

Severe odontogenic deep neck space infections: risk factors for difficult airways and ICU admissions

PURPOSE

The purpose of this retrospective study was to evaluate perioperative risk factors concerning difficult airway management, primary tracheostomy, and need for intensive care unit (ICU) admission in severe odontogenic space infections.

METHODS

Perioperative risk factors were retrospectively analyzed in 499 cases. Fisher's exact test and analysis of variance were performed to analyze associations between categorical and continuous variables. Univariate regression analysis was used for estimating predictors for ICU admission. A risk model for ICU admission was performed using multivariate regression analysis. Area-under-the-curve (AUC) was calculated by receiver-operating-characteristic (ROC) curve.

RESULTS

Airway securing in patients with restricted mouth opening led to significant use of the video laryngoscope (p < 0.001) or fiberoptic bronchoscope (p < 0.001). The use of fiberoptic bronchoscopy was significantly increased in patients with dysphagia (p = 0.005) and dyspnea (p = 0.04). Four patients (0.8%) needed primary tracheostomy. ICU admission was significantly associated with higher levels of C-reactive protein (CRP, p = 2.78 × 10^-5), white blood cell count (WBC, p = 0.003), dyspnea (p = 9.95 × 10^-6), and higher body mass index (BMI, p = 0.0003). American Society of Anesthesiologists physical status (ASA PS) class III patients (p = 0.04) and the need for the use of a video laryngoscopy (p = 0.003) or fiberoptic bronchoscopy (p = 6.58 × 10^-5) resulted in a more frequent ICU admission. The AUC of the model was 0.897.

CONCLUSION

Difficult airway management was mainly dependent on limited mouth opening and elevated CRP. Elevated CRP, BMI, ASA PS III, and dyspnea were important risk factors for ICU admission. These predictors should be considered preoperatively for proper planning and preparation.

Esophageal Heat Exchanger Versus Water-Circulating Cooling Blanket for Targeted Temperature Management

To date, the optimal cooling device for targeted temperature management (TTM) remains unclear. Water-circulating cooling blankets are broadly available and quickly applied but reveal inaccuracy during maintenance and rewarming period. Recently, esophageal heat exchangers (EHEs) have been shown to be easily inserted, revealed effective cooling rates (0.26-1.12°C/h), acceptable deviations from target core temperature (<0.5°C), and rewarming rates between 0.2 and 0.4°C/h. The aim of this study was to compare cooling rates, accuracy during maintenance, and rewarming period as well as side effects of EHEs with water-circulating cooling blankets in a porcine TTM model. Mean core temperature of domestic pigs (n = 16) weighing 83.2 ± 3.6 kg was decreased to a target core temperature of 33°C by either using EHEs or water-circulating cooling blankets. After 8 hours of maintenance, rewarming was started at a goal rate of 0.25°C/h. Mean cooling rates were 1.3 ± 0.1°C/h (EHE) and 3.2 ± 0.5°C/h (blanket, p < 0.0002). Mean difference to target core temperature during maintenance ranged between ±1°C. Mean rewarming rates were 0.21 ± 0.01°C/h (EHE) and 0.22 ± 0.02°C/h (blanket, n.s.). There were no differences with regard to side effects such as brady- or tachycardia, hypo- or hyperkalemia, hypo- or hyperglycemia, hypotension, shivering, or esophageal tissue damage. Target temperature can be achieved faster by water-circulating cooling blankets. EHEs and water-circulating cooling blankets were demonstrated to be reliable and safe cooling devices in a prolonged porcine TTM model with more variability in EHE group.

The Nomenclature, Definition and Distinction of Types of Shock

BACKGROUND

A severe mismatch between the supply and demand of oxygen is the common feature of all types of shock. We present a newly developed, clinically oriented classification of the various types of shock and their therapeutic implications.

METHODS

This review is based on pertinent publications (1990-2018) retrieved by a selective search in PubMed, and on the relevant guidelines and meta-analyses.

RESULTS

There are only four major categories of shock, each of which is mainly related to one of four organ systems. Hypovolemic shock relates to the blood and fluids compartment while distributive shock relates to the vascular system; cardiogenic shock arises from primary cardiac dysfunction; and obstructive shock arises from a blockage of the circulation. Hypovolemic shock is due to intravascular volume loss and is treated by fluid replacement with balanced crystalloids. Distributive shock, on the other hand, is a state of relative hypovolemia resulting from pathological redistribution of the absolute intravascular volume and is treated with a combination of vasoconstrictors and fluid replacement. Cardiogenic shock is due to inadequate function of the heart, which shall be treated, depending on the situation, with drugs, surgery, or other interventional procedures. In obstructive shock, hypoperfusion due to elevated resistance shall be treated with an immediate life-saving intervention.

CONCLUSION

The new classification is intended to facilitate the goal-driven treatment of shock in both the pre-hospital and the inpatient setting. A uniform treatment strategy should be established for each of the four types of shock.

Acupuncture reduces the time from extubation to 'ready for discharge' from the post anaesthesia care unit: results from the randomised controlled AcuARP trial

Acupuncture may improve peri-operative care as it reduces post-operative symptoms, such as pain, nausea and vomiting, or sedation. This patient-assessor blinded, randomised trial in 75 women undergoing gynaecologic laparoscopy evaluated the effects of acupuncture combined with a standardised anaesthetic regimen (ACU) on post-anaesthetic recovery, when compared to acupressure (APU) or standard anaesthesia alone (CON). Main outcome measure was the time from extubation to ‘ready for discharge’ from recovery as assessed by validated questionnaires. The main outcome differed significantly between groups (p = 0.013). Median time to ready for discharge in the ACU group (30 (IQR: 24–41) min) was 16 minutes (35%) shorter than in the CON group (46 (36–64) min; p = 0.015) and tended to be shorter than in the APU group (43 (31–58) min; p = 0.08). Compared to CON (p = 0.029), median time to extubation was approximately 7 minutes shorter in both, the ACU and the APU group. No acupuncture or acupressure-related side-effects could be observed. A difference in time to recovery of 16 minutes compared to standard alone can be considered clinically relevant. Thus, results of this study encourage the application of acupuncture in gynaecological laparoscopy as it improves post-anaesthetic recovery.

Evaluation of small intestinal damage in a rat model of 6 Minutes cardiac arrest

BACKGROUND

Contribution of the small intestine to systemic inflammation after cardiac arrest (CA) is poorly understood. The objective was to evaluate whether an in vivo rat model of 6 min CA is suitable to initiate intestinal ischaemia-reperfusion-injury and to evaluate histomorphological changes and inflammatory processes in the small intestinal mucosa resp. in sera.

METHODS

Adult male Wistar rats were subjected to CA followed by cardio-pulmonary resuscitation. Proximal jejunum and serum was collected at 6 h, 24 h, 72 h and 7 d post return of spontaneous circulation (ROSC) and from a control group. The small intestine was evaluated histomorphologically. Cytokine concentrations were measured in jejunum lysates and sera.

RESULTS

Histomorphological evaluation revealed a significant increase in mucosal damage in the jejunum at all timepoints compared to controls (p < 0.0001). In jejunal tissues, concentrations of IL-1α, IL-1β, IL-10, and TNF-α showed significant peaks at 24 h and were 1.5- to 5.7-fold higher than concentrations at 6 h and in the controls (p < 0.05). In serum, a significant higher amount of cytokine was detected only for IL-1β at 24 h post-ROSC compared to controls (15.78 vs. 9.76 pg/ml).

CONCLUSION

CA resulted in mild small intestinal tissue damage but not in systemic inflammation. A rat model of 6 min CA is not capable to comprehensively mimic a post cardiac arrest syndrome (PCAS). Whether there is a vital influence of the intestine on the PCAS still remains unclear.

[Update in Obstetric Anesthesia - Tried and Trusted Methods, Controversies and New Perspectives]

Since 1975, a plethora of lectures within the context of annual meetings relevant for the clinical care has been summarized in "what's new in obstetric anesthesia" by the society for Obstetric anesthesia and Perinatology which can be recommended to everyone interested in anaesthesiology in the delivery room. After the death of Gerard W. Ostheimer, Professor of Anaesthesiology at Brigham and Women's Hospital in Boston, Massachusetts, it became renamed the Gerard W. Ostheimer "what's new in obstetric anesthesia" lecture to honor his contributions to regional anesthesia and obstetric anaesthesia. Each year the event held by selected professional representatives and their imprint in leading anesthesia journals give insight into a critical appraisal of recent literature and the possible consequences for - but not only - the anaesthetic delivery room practice.A similar event has been established in Germany for more than 16 years (first event on April 1, 2000, most recently held on February 27, 2016, in Munich): the obstetrical anesthesia symposium of the academic working group "regional anesthesia and obstetrical anesthesia" [1], [2]."Evergreens" or "hot topics" with regard to anaesthesiological delivery room practice are presented and discussed regularly. The lectures often reveal the subtle change of the issues being debated much earlier than traditional textbook chapters do. This manuscript summarizes important findings from the last symposium held in 2016. Part I focuses on relevant causes for maternal morbidity and mortality as well as preventive measures, pregnancy in obese patients and sepsis in obstetric anaesthesia. Part II addresses established standards and new perspectives in the direct obstetric setting regarding epidural analgesia, post-dural puncture headache, anaesthesia and analgesia during and after caesarean section, haemodynamic monitoring during cesarean section and postpartum haemorrhage.

[Update in Obstetric Anesthesia: Tried and Trusted Methods, Controversies and New Perspectives - Part 1]

Since 1975, a plethora of lectures within the context of annual meetings relevant for the clinical care has been summarized in "what's new in obstetric anesthesia" by the Society for Obstetric Anesthesia and Perinatology which can be recommended to everyone interested in anaesthesiology in the delivery room. After the death of Gerard W. Ostheimer, Professor of Anaesthesiology at Brigham and Women's Hospital in Boston, Massachusetts, it became renamed the Gerard W. Ostheimer "what's new in obstetric anesthesia" lecture to honor his contributions to regional anesthesia and obstetric anaesthesia. Each year the event held by selected professional representatives and their imprint in leading anesthesia journals give insight into a critical appraisal of recent literature and the possible consequences for - but not only - the anaesthetic delivery room practice.A similar event has been established in Germany for more than 16 years: the obstetrical anesthesia symposium of the academic working group "regional anesthesia and obstetrical anesthesia" 1, 2."Evergreens" or "hot topics" with regard to anaesthesiological delivery room practice are presented and discussed regularly. The lectures often reveal the subtle change of the issues being debated much earlier than traditional textbook chapters do. This manuscript summarizes important findings from the last symposium held in 2016. Part I focuses on relevant causes for maternal morbidity and mortality as well as preventive measures, pregnancy in obese patients and sepsis in obstetric anaesthesia. Part II addresses established standards and new perspectives in the direct obstetric setting regarding epidural analgesia, post-dural puncture headache, anaesthesia and analgesia during and after caesarean section, haemodynamic monitoring during cesarean section and postpartum haemorrhage.

[Chest decompression in emergency medicine and intensive care]

Decompression of the chest is a life-saving invasive procedure for tension pneumothorax, trauma-associated cardiopulmonary resuscitation or massive haematopneumothorax that every emergency physician or intensivist must master. Particularly in the preclinical setting, indication must be restricted to urgent cases, but in these cases chest decompression must be executed without delay, even in subpar circumstances. The methods available are needle decompression or thoracentesis via mini-thoracotomy with or without insertion of a chest tube in the midclavicular line of the 2nd/3rd intercostal space (Monaldi-position) or in the anterior to mid-axillary line of the 4th/5th intercostal space (Bülau-position). Needle decompression is quick and does not require much material, but should be regarded as a temporary measure. Due to insufficient length of the usual 14-gauge intravenous catheters, the pleural cavity cannot be reached in a considerable percentage of patients. In the case of mini-thoracotomy, one must be cautious not to penetrate the chest inferior of the mammillary level, to employ blunt dissection techniques, to clearly identify the pleural space with a finger and not to use a trocar. In extremely urgent cases opening the pleural membrane by thoracostomy without inserting a chest tube is sufficient in mechanically ventilated patients. Complications are common and mainly include ectopic positions, which can jeopardise effectiveness of the procedure, sometimes fatal injuries to adjacent intrathoracic or - in case of too inferior placement - intraabdominal organs as well as haemorrhage or infections. By respecting the basic rules for safe chest decompression many of these complications should be avoidable.

[Perioperative management of transthoracic oesophagectomies : Fundamentals of interdisciplinary care and new approaches to accelerated recovery after surgery]

Locally advanced carcinomas of the oesophagus require multimodal treatment. The core element of curative therapy is transthoracic en bloc oesophagectomy, which is the standard procedure carried out in most specialized centres. Reconstruction of intestinal continuity is usually achieved with a gastric sleeve, which is anastomosed either intrathoracically or cervically to the remaining oesophagus. This thoraco-abdominal operation is associated with significant postoperative morbidity, not least because of a vast array of pre-existing illnesses in the surgical patient. For an optimal outcome, the careful interdisciplinary selection of patients, preoperative risk evaluation and conditioning are essential. The caseload of the centres correlates inversely with the complication rate. The leading surgical complication is anastomotic leakage, which is diagnosed endoscopically and usually treated with the aid of endoscopic procedures. Pulmonary infections are the most frequent non-surgical complication. Thoracic epidural anaesthesia and perfusion-orientated fluid management can reduce the rate of pulmonary complications. Patients are ventilated protecting the lungs and are extubated as early as possible. Oesophagectomies should only be performed in high-volume centres with the close cooperation of surgeons and anaesthesia/intensive care specialists. Programmes of enhanced recovery after surgery (ERAS) hold further potential for the patient's quicker postoperative recovery. In this review article the fundamental aspects of the interdisciplinary perioperative management of transthoracic oesophagectomy are described.

Sevoflurane mitigates shedding of hyaluronan from the coronary endothelium, also during ischemia/reperfusion: an ex vivo animal study

Glycosaminoglycan hyaluronan (HA), a major constituent of the endothelial glycocalyx, helps to maintain vascular integrity. Preconditioning the heart with volatile anesthetic agents protects against ischemia/reperfusion injury. We investigated a possible protective effect of sevoflurane on the glycocalyx, especially on HA. The effect of pre-ischemic treatment with sevoflurane (15 minutes at 2% vol/vol gas) on shedding of HA was evaluated in 28 isolated, beating guinea pig hearts, subjected to warm ischemia (20 minutes at 37°C) followed by reperfusion (40 minutes), half with and half without preconditioning by sevoflurane. HA concentration was measured in the coronary effluent. Over the last 20 minutes of reperfusion hydroxyethyl starch (1 g%) was continuously infused and the epicardial transudate collected over the last 5 minutes for measuring the colloid extravasation. Additional hearts were fixed by perfusion after the end of reperfusion for immunohistology and electron microscopy. Sevoflurane did not significantly affect post-ischemic oxidative stress, but strongly inhibited shedding of HA during the whole period, surprisingly even prior to ischemia. Immunohistology demonstrated that heparan sulfates and SDC1 of the glycocalyx were also preserved by sevoflurane. Electron microscopy revealed shedding of glycocalyx caused by ischemia and a mostly intact glycocalyx in hearts exposed to sevoflurane. Coronary vascular permeability of the colloid hydroxyethyl starch was significantly decreased by sevoflurane vs the control. We conclude that application of sevoflurane preserves the coronary endothelial glycocalyx, especially HA, sustaining the vascular barrier against ischemic damage. This may explain beneficial effects associated with clinical use of volatile anesthetics against ischemia/reperfusion injury.

RECCAS - REmoval of Cytokines during CArdiac Surgery: study protocol for a randomised controlled trial

Background

On-pump cardiac surgery triggers a significant postoperative systemic inflammatory response, sometimes resulting in multiple-organ dysfunction associated with poor clinical outcome. Extracorporeal cytokine elimination with a novel haemoadsorption (HA) device (CytoSorb®) promises to attenuate inflammatory response. This study primarily assesses the efficacy of intraoperative HA during cardiopulmonary bypass (CPB) to reduce the proinflammatory cytokine burden during and after on-pump cardiac surgery, and secondarily, we aim to evaluate effects on postoperative organ dysfunction and outcomes in patients at high risk.

Methods/design

This will be a single-centre randomised, two-arm, patient-blinded trial of intraoperative HA in patients undergoing on-pump cardiac surgery. Subjects will be allocated to receive either CPB with intraoperative HA or standard CPB without HA. The primary outcome is the difference in mean interleukin 6 (IL-6) serum levels between the two study groups on admission to the intensive care unit. A total number of 40 subjects was calculated as necessary to detect a clinically relevant 30 % reduction in postoperative IL-6 levels. Secondary objectives evaluate effects of HA on markers of inflammation up to 48 hours postoperatively, damage to the endothelial glycocalyx and effects on clinical scores and parameters of postoperative organ dysfunction and outcomes.

Discussion

In this pilot trial we try to assess whether intraoperative HA with CytoSorb® can relevantly reduce postoperative IL-6 levels in patients undergoing on-pump cardiac surgery. Differences in secondary outcome variables between the study groups may give rise to further studies and may lead to a better understanding of the mechanisms of haemoadsorption.

Trial registration

German Clinical Trials Register number DRKS00007928 (Date of registration 3 Aug 2015)

Zero-Heat-Flux Thermometry for Non-Invasive Measurement of Core Body Temperature in Pigs

Hypothermia is a severe, unpleasant side effect during general anesthesia. Thus, temperature surveillance is a prerequisite in general anesthesia settings during experimental surgeries. The gold standard to measure the core body temperature (T_core) is placement of a Swan-Ganz catheter in the pulmonary artery, which is a highly invasive procedure. Therefore, T_core is commonly examined in the urine bladder and rectum. However, these procedures are known for their inaccuracy and delayed record of temperatures. Zero-heat-flux (ZHF) thermometry is an alternative, non-invasive method quantifying T_core in human patients by applying a thermosensoric patch to the lateral forehead. Since the porcine cranial anatomy is different to the human’s, the optimal location of the patch remains unclear to date. The aim was to compare three different patch locations of ZHF thermometry in a porcine hypothermia model. Hypothermia (33.0°C T_core) was conducted in 11 anesthetized female pigs (26-30kg). T_core was measured continuously by an invasive Swan-Ganz catheter in the pulmonary artery (T_pulm). A ZHF thermometry device was mounted on three different defined locations. The smallest average difference between T_pulm and T_ZHF during stable temperatures was 0.21 ± 0.16°C at location A, where the patch was placed directly behind the eye. Also during rapidly changing temperatures location A showed the smallest bias with 0.48 ± 0.29°C. Location A provided the most reliable data for T_core. Therefore, the ZHF thermometry patch should be placed directly behind the left temporal corner of the eye to provide a non-invasive method for accurate measurement of T_core in pigs.

The effect of ghrelin upon the early immune response in lean and obese mice during sepsis

Introduction

It is well established that obesity-related hormones can have modulatory effects associated with the immune response. Ghrelin, a hormone mainly derived from endocrine cells of the gastric mucosa, regulates appetite, energy expenditure and body weight counteracting leptin, a hormone mainly derived from adipocytes. Additionally, receptors of both have been detected on immune cells and demonstrated an immune regulatory function during sepsis.

Methods

In the present study, the effect of peripheral ghrelin administration on early immune response and survival was investigated with lean mice and mice with diet-induced obesity using cecal ligation and puncture to induce sepsis.

Results

In the obese group, we found that ghrelin treatment improved survival, ameliorated hypothermia, and increased hyperleptinemia as compared to the lean controls. We also observed that ghrelin treatment divergently regulated serum IL-1ß and TNF-α concentrations in both lean and obese septic mice. Ghrelin treatment initially decreased but later resulted in increased bacteriaemia in lean mice while having no impact upon obese mice. Similarly, ghrelin treatment increased early neutrophil oxidative burst while causing a decrease 48 hours after sepsis inducement.

Conclusion

In conclusion, as the immune response to sepsis temporally changes, ghrelin treatment differentially mediates this response. Specifically, we observed that ghrelin conferred protective effects during the early phase of sepsis, but during the later phase deteriorated immune response and outcome. These adverse effects were more pronounced upon lean mice as compared to obese mice.

Acupuncture for post anaesthetic recovery and postoperative pain: study protocol for a randomised controlled trial

Background

We report on the design and implementation of a study protocol entitled Acupuncture randomised trial for post anaesthetic recovery and postoperative pain - a pilot study (ACUARP) designed to investigate the effectiveness of acupuncture therapy performed in the perioperative period on post anaesthetic recovery and postoperative pain.

Methods/Design

The study is designed as a randomised controlled pilot trial with three arms and partial double blinding. We will compare (a) press needle acupuncture, (b) no treatment and (c) press plaster acupressure in a standardised anaesthetic setting. Seventy-five patients scheduled for laparoscopic surgery to the uterus or ovaries will be allocated randomly to one of the three trial arms. The total observation period will begin one day before surgery and end on the second postoperative day. Twelve press needles and press plasters are to be administered preoperatively at seven acupuncture points. The primary outcome measure will be time from extubation to ‘ready for discharge’ from the post anaesthesia care unit (in minutes). The ‘ready for discharge’ end point will be assessed using three different scores: the Aldrete score, the Post Anaesthetic Discharge Scoring System and an In-House score. Secondary outcome measures will comprise pre-, intra- and postoperative variables (which are anxiety, pain, nausea and vomiting, concomitant medication).

Discussion

The results of this study will provide information on whether acupuncture may improve patient post anaesthetic recovery. Comparing acupuncture with acupressure will provide insight into potential therapeutic differences between invasive and non-invasive acupuncture techniques.

Trial registration

NCT01816386 (First received: 28 October 2012)

Platelet mitochondrial membrane depolarization reflects disease severity in patients with sepsis and correlates with clinical outcome

Introduction

Sepsis is still a leading cause of morbidity and mortality, even in modern times, and thrombocytopenia has been closely associated with unfavorable disease outcome. Decreases in mitochondrial membrane potential (depolarization) were found in different tissues during sepsis. Previous work suggests that mitochondrial dysfunction of platelets correlates with clinical disease activity in sepsis. However, platelet mitochondrial membrane potential (Mmp) has not been investigated in a clinical follow-up design and not with regard to disease outcome.

Methods

In this study, platelet mitochondrial membrane depolarization was assessed by means of a fluorescent Mmp-Index with flow cytometry in 26 patients with sepsis compared with control patients. Platelet Mmp-Index on admission was correlated with the clinical disease scores Acute Physiology and Chronic Health Evaluation Score II (APACHE II), Sequential Organ Failure Score (SOFA), and Simplified Acute Physiology Score II (SAPS II). Finally, platelet Mmp-Index on admission and follow-up were compared in the group of sepsis survivors and nonsurvivors. Expression of the prosurvival protein Bcl-xL in platelets was quantified by immunoblotting.

Results

Platelet mitochondrial membrane depolarization correlated significantly with the simultaneously assessed clinical disease severity by APACHE II (r = -0.867; P < 0.0001), SOFA (r = -0.857; P <0.0001), and SAPS II score (r = -0.839; P < 0.0001). Patients with severe sepsis showed a significant reduction in platelet Mmp-Index compared with sepsis without organ failure (0.18 (0.12 to 0.25) versus 0.79 (0.49 to 0.85), P < 0.0006) or with the control group (0.18 (0.12 to 0.25) versus 0.89 (0.68 to 1.00), P < 0.0001). Platelet Mmp-Index remained persistently low in sepsis nonsurvivors (0.269 (0.230 to 0.305)), whereas we observed recovery of platelet Mmp-Index in the survivor group (0.9 (0.713 to 1.017)). Furthermore, the level of prosurvival protein Bcl-xL decreased in platelets during severe sepsis.

Conclusion

In this study, we demonstrated that mitochondrial membrane depolarization in platelets correlates with clinical disease severity in patients with sepsis during the disease course and may be a valuable adjunct parameter to aid in the assessment of disease severity, risk stratification, and clinical outcome.

Ischemia-reperfusion-induced unmeasured anion generation and glycocalyx shedding: sevoflurane versus propofol anesthesia

INTRODUCTION

Vascular leakage after ischemia-reperfusion (IR) is largely attributed to the destruction of the endothelial barrier and its associated negatively charged glycocalyx. In vitro, sevoflurane attenuates these changes. Therefore, we compared sevoflurane with propofol with regard to the protection of the glycocalyx and the release of negatively charged substances in vivo.

METHODS

After surgical preparation under midazolam-fentanyl, nine pigs each received either propofol or sevoflurane. Ischemia of 90 min was induced by a balloon catheter in the thoracic aorta. After 120 min of reperfusion, the anesthetics were changed back to midazolam-fentanyl. Five animals, each without aortic occlusion, served as time controls. Blood electrolyte parameters were measured, from which the strong ion gap (SIG) was calculated. Serum heparan sulfate concentrations and immunohistology served as a marker of glycocalyx destruction.

RESULTS

Immediately after reperfusion, SIG increased significantly only in the propofol group (+6.7 mEq/l versus baseline; p < .05), remaining stable in sevoflurane and both time-controlled groups. Initially, heparan sulfate concentration increased comparably in both experimental groups, but after 120 min, it became stable in sevoflurane-anesthetized animals, while increasing further in the propofol group (p < .05).

CONCLUSIONS

Unmeasured anions, predictive of negative outcome in previous studies, did not increase significantly in sevoflurane-anesthetized animals. Additionally, there was less heparan sulfate shedding over time, signaling less destruction of the glycocalyx. Therefore, in this in-vivo situation, sevoflurane proves to be superior to propofol in protecting the endothelium from IR injury.

[Tuberculous encephalitis, Landouzy sepsis and Pott's disease: complications after surgery for spinal stenosis]

Tuberculosis is an infectious disease with a decreasing incidence in Germany. In particular, the occurrence of reinfections and possible complications associated with this disease, such as tuberculous meningitis/encephalitis and Landouzy sepsis are rare in industrial countries. In this article the intensive care treatment of a patient who initially underwent surgery for spinal stenosis is reported. Due to recurrent appearance of neurological symptoms with increasing severity and abscess formation in the spine, further surgery was performed. Additionally, the patient developed sepsis and meningitis. At this time an infection with Mycobacterium tuberculosis could be detected in both cerebrospinal fluid and abscess material of the spine suggesting a Landouzy sepsis, tuberculous meningitis/encephalitis and the suspicion of an underlying Pott's disease.

[Nutritional management of severely injured patients : Treatment between guidelines and reality]

Severe trauma triggers endocrine and inflammatory responses, leading to hyperglycaemia, insulin resistance and protein catabolism. Pharmacological and nutritional interventions cannot counteract these metabolic disturbances. However, adequate supply of energy and proteins may reduce excessive catabolism.Available guidelines recommend early use of enteral nutrition with energetic supply of about 25 kcal/kg and additional protein supply of 1.5 g/kg/day. These aims will be missed frequently by solely providing enteral nutrition in severely injured patients. Early supplemental parenteral nutrition should be used in these cases. Concomitantly, gastric paresis and paralytic ileus hampering enteral nutrition should be treated by propulsive and prokinetic drugs and by use of duodenal or jejunal site of application in selected cases.Euphoric hopes linked with intensified insulin therapy (IIT), targeting blood glucose levels <110 mg/dl in intensive care patients, had to be widely abandoned in recent years. The goal for blood glucose levels should be set at 180 mg/dl as the upper limit according to current knowledge, which promises to optimize the balance between efficacy and safety.

Inosine, not adenosine, initiates endothelial glycocalyx degradation in cardiac ischemia and hypoxia

Ischemia/reperfusion and hypoxia/reoxygenation of the heart both induce shedding of the coronary endothelial glycocalyx. The processes leading from an oxygen deficit to shedding are unknown. An involvement of resident perivascular cardiac mast cells has been proposed. We hypothesized that either adenosine or inosine or both, generated by nucleotide catabolism, attain the concentrations in the interstitial space sufficient to stimulate A3 receptors of mast cells during both myocardial ischemia/reperfusion and hypoxia/reoxygenation. Isolated hearts of guinea pigs were subjected to either normoxic perfusion (hemoglobin-free Krebs-Henseleit buffer equilibrated with 95% oxygen), 20 minutes hypoxic perfusion (buffer equilibrated with 21% oxygen) followed by 20 minutes reoxygenation, or 20 minutes stopped-flow ischemia followed by 20 minutes normoxic reperfusion (n = 7 each). Coronary venous effluent was collected separately from so-called transudate, a mixture of interstitial fluid and lymphatic fluid appearing on the epicardial surface. Adenosine and inosine were determined in both fluid compartments using high-performance liquid chromatography. Damage to the glycocalyx was evident after ischemia/reperfusion and hypoxia/reoxygenation. Adenosine concentrations rose to a level of 1 μM in coronary effluent during hypoxic perfusion, but remained one order of magnitude lower in the interstitial fluid. There was only a small rise in the level during postischemic perfusion. In contrast, inosine peaked at over 10 μM in interstitial fluid during hypoxia and also during reperfusion, while effluent levels remained relatively unchanged at lower levels. We conclude that only inosine attains levels in the interstitial fluid of hypoxic and postischemic hearts that are sufficient to explain the activation of mast cells via stimulation of A3-type receptors.