[Placement of a central venous catheter in cases of persistent left superior vena cava]

This article presents a case report on the placement of a central venous catheter (CVC) in a patient with an unknown persistent left superior vena cava (PLSVC). Normally, PLSVCs remain asymptomatic but can be associated with disastrous consequences for the patient during placement of a CVC particularly due to vascular perforation and pulmonary injury. A PLSCV is particularly common in association with congenital heart defects; however, otherwise healthy patients can also be affected. As the presence of a PLSCV is normally unknown special attention must be paid in every patient during placement of a CVC.

How often should we monitor for reliable detection of atrial fibrillation recurrence? Efficiency considerations and implications for study design

Objective

Although atrial fibrillation (AF) recurrence is unpredictable in terms of onset and duration, current intermittent rhythm monitoring (IRM) diagnostic modalities are short-termed and discontinuous. The aim of the present study was to investigate the necessary IRM frequency required to reliably detect recurrence of various AF recurrence patterns.

Methods

The rhythm histories of 647 patients (mean AF burden: 12±22% of monitored time; 687 patient-years) with implantable continuous monitoring devices were reconstructed and analyzed. With the use of computationally intensive simulation, we evaluated the necessary IRM frequency to reliably detect AF recurrence of various AF phenotypes using IRM of various durations.

Results

The IRM frequency required for reliable AF detection depends on the amount and temporal aggregation of the AF recurrence (p<0.0001) as well as the duration of the IRM (p<0.001). Reliable detection (>95% sensitivity) of AF recurrence required higher IRM frequencies (>12 24-hour; >6 7-day; >4 14-day; >3 30-day IRM per year; p<0.0001) than currently recommended. Lower IRM frequencies will under-detect AF recurrence and introduce significant bias in the evaluation of therapeutic interventions. More frequent but of shorter duration, IRMs (24-hour) are significantly more time effective (sensitivity per monitored time) than a fewer number of longer IRM durations (p<0.0001).

Conclusions

Reliable AF recurrence detection requires higher IRM frequencies than currently recommended. Current IRM frequency recommendations will fail to diagnose a significant proportion of patients. Shorter duration but more frequent IRM strategies are significantly more efficient than longer IRM durations.

Clinical Trial Registration URL

Unique identifier: NCT00806689.

Successful isavuconazole salvage therapy in a patient with invasive mucormycosis

A 45-year-old male with rhinocerebral mucormycosis (Rhizopus oryzae), refractory to liposomal amphotericin B and posaconazole, received isavuconazole salvage therapy. Initial isavuconazole plasma and tissue levels were 0.76-0.86 μg/mL and 1.09-1.38 μg/g. Plasma levels increased to 1.3-3.24 μg/mL with reduced comedication. Isavuconazole was well tolerated, and the patient has remained disease-free 24 months post-antifungal therapy.

First experience with the deltastream(R) DP3 in venovenous extracorporeal membrane oxygenation and air-supported inter-hospital transport

OBJECTIVES

Based on continuous technical innovations and recent research, extracorporeal membrane oxygenation (ECMO) has become a promising tool in the treatment of patients with acute (cardio)pulmonary failure. Nevertheless, any extracorporeal technique requires a high degree of experience and knowledge, so that a restriction to specialized centres seems to be reasonable. As a consequence of this demand, the need for inter-hospital transfer of patients with severely impaired (cardio)pulmonary function is rising. Unfortunately, most of the ECMO devices used in the clinical setting are not suitable for inter-hospital transport because of their size, weight or complexity. In this article, we describe our first experiences with the airborne transport of 6 patients on a new portable, miniaturized and lightweight extracorporeal circulation system, the Medos deltastream® DP3.

METHODS

Six patients suffering acute respiratory failure were taken on venovenous ECMO (DP3) out-of-centre and transferred to the University Medical Center Regensburg by helicopter. All cardiorespiratory-relevant parameters of the patients and the technical functioning of the device were continuously monitored and documented.

RESULTS

Implantation of the device and air-supported transport were performed without any technical complications. The patients were transported from a distance of 66-178 km, requiring a time of 40-120 min. With the help of the new deltastream® DP3 ECMO device, a prompt stabilization of the cardiopulmonary function could be achieved in all patients. One patient was under ongoing cardiopulmonary resuscitation by the time our ECMO team arrived at the peripheral hospital and died shortly after arrival in the central emergency ward.

CONCLUSIONS

Our experience shows that the deltastream® DP3 is an absolutely reliable and safe ECMO device that could gain growing importance in the field of airborne transportation of patients on ECMO due to its unsophisticated, miniaturized and lightweight characteristics.

Extracorporeal lung support in trauma patients with severe chest injury and acute lung failure: a 10-year institutional experience

Introduction

Severe trauma with concomitant chest injury is frequently associated with acute lung failure (ALF). This report summarizes our experience with extracorporeal lung support (ELS) in thoracic trauma patients treated at the University Medical Center Regensburg.

Methods

A retrospective, observational analysis of prospectively collected data (Regensburg ECMO Registry database) was performed for all consecutive trauma patients with acute pulmonary failure requiring ELS during a 10-year interval.

Results

Between April 2002 and April 2012, 52 patients (49 male, three female) with severe thoracic trauma and ALF refractory to conventional therapy required ELS. The mean age was 32 ± 14 years (range, 16 to 72 years). Major traffic accident (73%) was the most common trauma, followed by blast injury (17%), deep fall (8%) and blunt trauma (2%). The mean Injury Severity Score was 58.9 ± 10.5, the mean lung injury score was 3.3 ± 0.6 and the Sequential Organ Failure Assessment score was 10.5 ± 3. Twenty-six patients required pumpless extracorporeal lung assist (PECLA) and 26 patients required veno-venous extracorporeal membrane oxygenation (vv-ECMO) for primary post-traumatic respiratory failure. The mean time to ELS support was 5.2 ± 7.7 days (range, <24 hours to 38 days) and the mean ELS duration was 6.9 ± 3.6 days (range, <24 hours to 19 days). In 24 cases (48%) ELS implantation was performed in an external facility, and cannulation was done percutaneously by Seldinger's technique in 98% of patients. Cannula-related complications occurred in 15% of patients (PECLA, 19% (n = 5); vv-ECMO, 12% (n = 3)). Surgery was performed in 44 patients, with 16 patients under ELS prevention. Eight patients (15%) died during ELS support and three patients (6%) died after ELS weaning. The overall survival rate was 79% compared with the proposed Injury Severity Score-related mortality (59%).

Conclusion

Pumpless and pump-driven ELS systems are an excellent treatment option in severe thoracic trauma patients with ALF and facilitate survival in an experienced trauma center with an interdisciplinary treatment approach. We encourage the use of vv-ECMO due to reduced complication rates, better oxygenation and best short-term outcome.

Extracorporeal pulmonary support in severe pulmonary failure in adults: a treatment rediscovered

BACKGROUND

Severe, acute respiratory failure in adults still carries a high mortality. In recent years, improved pulmonary support techniques have been used increasingly alongside conventional treatment. About 1000 such treatments are performed in Germany annually, and the number is rising rapidly. The two types of systems currently in use involve venovenous extracorporeal membrane oxygenation (ECMO) and extracorporeal carbon dioxide elimination.

METHODS

The underlying principles, technical implementation, efficacy, and adverse effects of the new techniques are summarized in the light of a selective review of the literature, supplemented by the authors' personal experience. Recommendations are given for clinical use.

RESULTS

Currently, only limited high-quality data (from prospective randomized trials) are available to support the use of either of these techniques in adults. Veno-venous ECMO systems can effectively secure gas exchange in patients with severe respiratory failure, with experienced centers reporting survival rates from 63% to 75%. Either pump-free arteriovenous systems or low-flow ECMO systems can be used for extracorporeal carbon dioxide elimination. Complications can be serious or life-threatening and must, therefore, be rapidly recognized and treated: these include vascular injury during cannulation, venous thrombosis in a cannulated vessel, an increased hemorrhagic tendency, and thrombocytopenia.

CONCLUSION

Modern miniaturized pulmonary support systems enable protective mechanical ventilation with low tidal volumes, reduce ventilator-associated lung injury, and can improve survival rates in critically ill patients with a manageable adverse effect profile.

[Secondary sclerosing cholangitis after multiple trauma and long-term intensive care treatment: case report of a characteristic course]

This article reports on a patient who needed intensive care treatment because of multiple trauma. The patient had no preexisting liver disease but developed secondary sclerosing cholangitis and finally died. The etiology, diagnosis and therapeutic options of this clinical picture are discussed and a review of the literature is presented.

The effect of perchlorate medication on point-of-care testing

BACKGROUND

To create awareness for mismeasurements of ion-selective electrodes caused by patients' medications and to prevent severe consequences in an intensive care therapy.

CASE PRESENTATION

A 73-year-old woman presented with severe carbimazol-induced toxic epidermal necrolysis. After replacement of carbimazol by sodiumperchlorate, we detected a huge discrepancy in the measurement of ionised calcium by two different Point-of-Care (POCT) systems. While Siemens Rapidlab 865 showed a severe hypocalcemia at all times, the Radiometer 600 system first presented a severe hypercalcemia and, in the course of the following days, also a hypocalcemia but with significantly (p < 10 to the -45) higher values than the Rapidlab system. Furthermore, the POCT systems detected a pseudohypocalcemia at times where we think there was a normo- or even hypercalcemia which led to incorrect therapy with excessive substitution of ionised calcium.

CONCLUSIONS

The substance sodiumperchlorate, which is well established in Europe for hyperthyreosis therapy, caused malfunctions of analyses of ionised calcium by POCT systems.

Comparison of point-of-care testing glucose results from intensive care patients measured with network-ready devices

BACKGROUND

Fast and reliable glycemic control is of tremendous importance in intensive care units. Point-of-care devices used in professional care have to be precise and of low variability, and their connectivity has to outrange the abilities of home-care equivalents. In particular, the meter's efficiency should be tested not only with spiked blood samples from healthy donors but also with blood from intensive care unit patients because of their special matrix conditions as low hematocrit, oxygen pressure variability, or medication.

METHODS

Four types of network-ready glucose meters were tested. Data, obtained from native or maltose/xylose-spiked intensive care patients' blood, were compared (oxygen, hematocrit, glucose, and maltose and xylose dependencies) with those from a YSI 2300 STAT Plus™ glucose and lactate analyzer (YSI Life Sciences, Yellow Springs, OH). According to ISO 15197 (2003) acceptance of glucose meter results was determined. Quality control results were investigated considering a new calculation type in German guidelines.

RESULTS

Three of the meters fulfill the overall acceptance criterions. Two of the meters achieved accuracies above 93% in all oxygen, hematocrit, and glucose subgroups. Maltose generates deviations leading to accuracies from 71.1% to 100%, and xylose causes accuracies of 33.3% to 100%.

CONCLUSIONS

State of the art for manufacturing small network point-of-care testing glucose meters has reached a new level of precision, but the devices still have to be handled with care, and in particular the staff of an intensive care unit still needs knowledge about possible interferences.

Is the alpine divide becoming more permeable to biological invasions? - Insights on the invasion and establishment of the Walnut Husk Fly, Rhagoletis completa (Diptera: Tephritidae) in Switzerland

The Walnut Husk Fly, Rhagoletis completa Cresson (Diptera: Tephritidae), is native to North America (Midwestern US and north-eastern Mexico) and has invaded several European countries in the past decades by likely crossing the alpine divide separating most parts of Switzerland from Italy. Here, we determined its current distribution in Switzerland by sampling walnuts (Juglans regia L.) in ecologically and climatically distinct regions along potential invasion corridors. R. completa was found to be firmly established in most low altitude areas of Switzerland where walnuts thrive, but notably not a single parasitoid was recovered from any of the samples. Infested fruit was recovered in 42 of the 71 localities that were surveyed, with mean fruit infestation rate varying greatly among sites. The incidence of R. completa in Switzerland is closely related to meteorological mean spring temperature patterns influencing growing season length, but not to winter temperatures, reflecting survival potential during hibernation. Importantly, areas in which the fly is absent correspond with localities where the mean spring temperatures fall below 7°C. Historical data records show that the natural cold barrier around the Alpine divide in the central Swiss Alps corresponding to such minimal temperatures has shrunk significantly from a width of more than 40 km before 1990 to around 20 km after 2000. We hypothesize on possible invasion/expansion routes along alpine valleys, dwell on distribution patterns in relation to climate, and outline future research needs as the incursion of R. completa into Switzerland; and, more recently, other European countries, such as Germany, Austria, France and Slovenia, represent an example of alien species that settle first in the Mediterranean Basin and from there become invasive by crossing the Alps.

Oxidative stress induces senescence in chondrocytes

Cellular senescence is a program activated during diverse situations of cell stress. Chondrocytes differ from other somatic cells as articular cartilage is an avascular tissue. The effects of oxidative stress on chondrocytes are still unknown. Our studies were to investigate into the proliferation potential, cytological features and the telomere linked stress response system of human osteoarthritic chondrocytes, subjected to acute or prolonged oxidant challenge with hydrogen peroxide. Telomere length was measured using the telomere restriction fragment assay, gene expression was determined by RT-PCR. Sub-lethal doses of oxidative stress induced cell-cycle arrest, senescent-morphological features and senescence-associated β-galactosidase positivity. Prolonged oxidative treatment had no effects on cell proliferation or morphology. Sub-lethal and prolonged low doses of oxidative stress considerably accelerated telomere attrition. The effects of sub-lethal oxidative stress regarding proliferation and telomere biology were more distinct in senescent cells. Acute oxidant insult caused up-regulation of p21 expression to levels comparable to senescent cells. TRF2 protects telomere ends and showed elevated expression levels. SIRT1 and XRCC5 enable cells to cope with unfavorable growing conditions. Both were up-regulated after oxidant insult, but expression levels decreased in aging cells. Taken together, oxidative stress considerably accelerated telomere shortening and cellular aging in chondrocytes. Senescent cells showed a reduced tolerance to oxidative stress.

First experience with the ultra compact mobile extracorporeal membrane oxygenation system Cardiohelp in interhospital transport

In patients with severe cardiopulmonary failure extracorporeal assist devices are to support patients during resuscitation, for transportation, until organ recovery, and as bridge to further therapeutic modalities. We report on our first experience with the new Cardiohelp system for interhospital transfer of cardiopulmonarily compromised patients. The Cardiohelp system was used for transportation and in-house treatment in six male patients with a mean age of 41±17 years. Five patients suffered respiratory failure; one patient with acute myocardial infarction was in profound cardiogenic shock. Accordingly, the Cardiohelp system was implanted as a venovenous extracorporeal membrane oxygenation (ECMO) in five patients and as a venoarterial system in one patient. The preECMO ventilation time was 0.5-4 days. The patients were transported to our institution by car (n=1) or helicopter (n=5) over a distance of 80-5850 km. The subsequent in-house ECMO support was continued with the Cardiohelp and lasted for 5-13 days. PostECMO ventilation was one to 25 days. A 100% survival was achieved. The portable Cardiohelp system allows location-independent stabilization of cardiopulmonary compromised patients with consecutive interhospital transfer and in-house treatment. The integrated sensors, which register arterial and venous line pressure, blood temperature, hemoglobin as well as SvO(2), greatly alleviate its management and considerably increase safety.

Immunomodulation of neutrophil–endothelial interaction by inotropes

OBJECTIVE

To evaluate the effect of the inotropes epinephrine, dopamine and dobutamine on expression of endothelial adhesion molecules and on neutrophil adhesion to endothelial cells under dynamic conditions.

METHODS

Endothelial cells were obtained by collagenase digestion of human umbilical cord veins.Endothelial monolayers were pre-incubated with one of the chosen inotropes, with or without butoxamine, and exposed to interleukin-1. The monolayers were then incubated with fluorescencelabelled anti-human monoclonal antibodies directed against the endothelial adhesion molecules ICAM-1, E-selectin or VCAM-1. Expression of endothelial adhesion molecules was analysed by flow cytometry after pre-incubation of endothelial monolayers with one of the chosen inotropes, with or without butoxamine, and after exposure to interleukin-1. To evaluate the neutrophil adherence, the endothelium was placed on a horizontal shaker-incubator and overlayered with neutrophils. Then, non-adherent neutrophils were removed, and cells were completely dissociated. Finally, neutrophils and endothelial cells were counted by flow cytometry.

RESULTS

The expression of E-selectin on endothelium following stimulation with interleukin-1 is attenuated by the inotropes dopamine or dobutamine, but not by epinephrine. The addition of butoxamine does not modify the expression of E-selectin following stimulation with interleukin-1 and pre-incubation with one of the chosen inotropes. The decrease in neutrophil adhesion to endothelium following stimulation with interleukin-1 and addition of inotropes is antagonised by the b-blocker butoxamine.

CONCLUSION

In contrast to the modulation of E-selectin expression on endothelium, the effect of inotropes on neutrophil adhesion to endothelium is regulated by the expression of adhesion molecules on PMNs and mediated by the b-adrenoceptor.

Major adverse cardiac and cerebrovascular events after the Ross procedure: a report from the German-Dutch Ross Registry

BACKGROUND

The purpose of the study is to report major cardiac and cerebrovascular events after the Ross procedure in the large adult and pediatric population of the German-Dutch Ross registry. These data could provide an additional basis for discussions among physicians and a source of information for patients.

METHODS AND RESULTS

One thousand six hundred twenty patients (1420 adults; 1211 male; mean age, 39.2±16.2 years) underwent a Ross procedure between 1988 and 2008. Follow-up was performed on an annual basis (median, 6.2 years; 10 747 patient-years). Early and late mortality were 1.2% (n=19) and 3.6% (n=58; 0.54%/patient-year), respectively. Ninety-three patients underwent 99 reinterventions on the autograft (0.92%/patient-year); 78 reinterventions in 63 patients on the pulmonary conduit were performed (0.73%/patient-year). Freedom from autograft or pulmonary conduit reoperation was 98.2%, 95.1%, and 89% at 1, 5, and 10 years, respectively. Preoperative aortic regurgitation and the root replacement technique without surgical autograft reinforcement were associated with a greater hazard for autograft reoperation. Major internal or external bleeding occurred in 17 (0.15%/patient-year), and a total of 38 patients had composite end point of thrombosis, embolism, or bleeding (0.35%/patient-year). Late endocarditis with medical (n=16) or surgical treatment (n=29) was observed in 38 patients (0.38%/patient-year). Freedom from any valve-related event was 94.9% at 1 year, 90.7% at 5 years, and 82.5% at 10 years.

CONCLUSIONS

Although longer follow-up of patients who undergo Ross operation is needed, the present series confirms that the autograft procedure is a valid option to treat aortic valve disease in selected patients. The nonreinforced full root technique and preoperative aortic regurgitation are predictors for autograft failure and warrant further consideration. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT00708409.

Restoration of neutrophil immunocompetence after cardiopulmonary bypass by beta-adrenergic blockers

BACKGROUND

To evaluate the possible protective effect of sympatholytic medications with respect to neutrophil function, we evaluated the influence of a nonselective beta-blocker medication on the interaction of neutrophils and epinephrine after cardiopulmonary bypass. Therefore, we studied the importance of adrenoceptors for the immunomodulation of neutrophils by catecholamines in vitro.

METHODS

First, we investigated the modulation of neutrophils from healthy volunteers, after stimulation with n-formyl-l-methionyl-l-leucyl-l-phenylalanin (FMLP) in the presence of epinephrine with or without the addition of one of the following adrenergic receptor antagonists: atenolol, butoxamine, pindolol, prazosin, or RS79984. The second part included an investigation of the modulation of neutrophils from patients after operative coronary revascularization with or without extracorporeal circulation after stimulation with FMLP and addition of epinephrine. After loading with anti-CD62l or anti-CD11b antibodies or dihydrorhodamine, the expression of CD62l and CD11b and generation of oxidative free radicals were assessed by flow cytometry.

RESULTS

The suppression of oxidative free radical generation, inhibition of CD62l downregulation after stimulation with FMLP, and suppression of CD11b upregulation after FMLP stimulation from epinephrine were all mediated by beta(2)-adrenoceptors. After cardiac surgery with cardiopulmonary bypass, epinephrine inhibited the CD62l downregulation, the suppression of CD11b upregulation, and the generation of oxidative free radicals after FMLP stimulation. The pre-operative administration of beta-blockers abolished the immunomodulatory effects of epinephrine on CD62l and CD11b expression and the generation of oxidative free radicals.

CONCLUSION

The immunomodulatory effects of epinephrine on neutrophils remained unchanged irrespective of cardiopulmonary bypass and could contribute to the detrimental effects of epinephrine after heart surgery. The preoperative administration of nonselective beta-blockers abolished the immunomodulatory effects of epinephrine in vitro and in patients, and it enhanced the immunocompetence of neutrophils in a context of increased catecholamine levels.

Emergency use of extracorporeal membrane oxygenation in cardiopulmonary failure

Severe pulmonary and cardiopulmonary failure resistant to critical care treatment leads to hypoxemia and hypoxia-dependent organ failure. New treatment options for cardiopulmonary failure are necessary even for patients in outlying medical facilities. If these patients are in need of specialized center treatment, additional emergency medical service has to be carried out quick and safely. We describe our experiences with a pumpless extracorporeal lung assist (PECLA/iLA) for out-of-center emergency treatment of hypercapnic respiratory failure and the use of a newly developed hand-held extracorporeal membrane oxygenation (ECMO) system in cardiac, pulmonary, and cardiopulmonary failure (EMERGENCY-LIFE Support System, ELS System, MAQUET Cardiopulmonary AG, Hechingen, Germany). Between March 2000 and April 2009, we used the PECLA System (n = 20) and the ELS System (n = 33) in adult patients. Cannulation was employed using percutaneous vessel access. The new hand-held ELS System consists of a centrifugal pump and a membrane oxygenator, both mounted on a special holder system for storing on a standard patient gurney for air or ground ambulance transfer. Bedside cannulation processes were uneventful. The PECLA System resulted in sufficient CO(2) removal. In all ECMO patients, oxygen delivery and systemic blood flow could be restored and vasopressor support was markedly down. Hospital survival rate in the PECLA group was 50%, and 61% in the ECMO group. Out-of-center emergency treatment of hypercapnic pulmonary failure with pumpless extracorporeal gas exchange and treatment of cardiac, pulmonary, and cardiopulmonary failure with this new hand-held ECMO device is safe and highlyeffective. Patient outcome in cardiopulmonary organ failure could be improved.