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).

Extravascular lung water levels are associated with mortality: a systematic review and meta-analysis

Background

The prognostic value of extravascular lung water (EVLW) measured by transpulmonary thermodilution (TPTD) in critically ill patients is debated. We performed a systematic review and meta-analysis of studies assessing the effects of TPTD-estimated EVLW on mortality in critically ill patients.

Methods

Cohort studies published in English from Embase, MEDLINE, and the Cochrane Database of Systematic Reviews from 1960 to 1 June 2021 were systematically searched. From eligible studies, the values of the odds ratio (OR) of EVLW as a risk factor for mortality, and the value of EVLW in survivors and non-survivors were extracted. Pooled OR were calculated from available studies. Mean differences and standard deviation of the EVLW between survivors and non-survivors were calculated. A random effects model was computed on the weighted mean differences across the two groups to estimate the pooled size effect. Subgroup analyses were performed to explore the possible sources of heterogeneity.

Results

Of the 18 studies included (1296 patients), OR could be extracted from 11 studies including 905 patients (464 survivors vs. 441 non-survivors), and 17 studies reported EVLW values of survivors and non-survivors, including 1246 patients (680 survivors vs. 566 non-survivors). The pooled OR of EVLW for mortality from eleven studies was 1.69 (95% confidence interval (CI) [1.22; 2.34], p < 0.0015). EVLW was significantly lower in survivors than non-survivors, with a mean difference of −4.97 mL/kg (95% CI [−6.54; −3.41], p < 0.001). The results regarding OR and mean differences were consistent in subgroup analyses.

Conclusions

The value of EVLW measured by TPTD is associated with mortality in critically ill patients and is significantly higher in non-survivors than in survivors. This finding may also be interpreted as an indirect confirmation of the reliability of TPTD for estimating EVLW at the bedside. Nevertheless, our results should be considered cautiously due to the high risk of bias of many studies included in the meta-analysis and the low rating of certainty of evidence.

Trial registration the study protocol was prospectively registered on PROSPERO: CRD42019126985.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-022-04061-6.

Potential impact of cell-free DNA blood testing in the diagnosis of sepsis

BACKGROUND

Classical blood culture testing is still the gold standard in correct and timely diagnosis of the responsible microorganisms in sepsis.

CASE SUMMARY

In this case (a patient with a colon perforation and severe peritonitis with septic shock), an alternative approach (cell-free DNA next-generation sequencing from full blood samples, NGS) showed the responsible microorganisms, whereas the classical blood culture testing remainedstayed sterile. Interestingly, samples from the abdominal fluid showed the same bacteria as NGS.

CONCLUSION

These findings may be interpreted as that the threshold for positive testing is lower through the molecular approach than through culture techniques; however, more studies are necessary to prove this theory.

[Severe Candida sepsis in a 28-year-old female patient with initial diagnosis of diabetes mellitus and marked hyperosmolar coma]

We report on a 28-year-old female patient who had no history of diseases and who was brought to our intensive care unit in a comatose state by the ambulance service. The clinical picture corresponded to sepsis with a massively increased blood sugar concentration (> 2000 mg/dl) as well as a pronounced skin mycosis in the groin region of the very obese patient (body mass index [BMI]: 33.7 kg/m²) in the physical examination. The treatment of sepsis was initially supplemented by a calculated antifungal treatment. The blood culture diagnosis confirmed the presence of Candida albicans and Candida glabrata. Despite adequate anti-infective treatment, the patient developed a septic shock in the further course, so that the additional escalation of treatment was initiated by renal replacement therapy on the second day and venovenous extracorporeal membrane oxygenation because of an ARDS. Despite all of these measures and maximum intensive care treatment, the patient developed a progressive multiple organ failure. When the pupils became rigid to light, a cerebral computed tomography was carried out. This showed evidence of a severe cerebral edema without signs of cerebral bleeding. Multiple examinations of somatosensory evoked potentials and electroencephalograms showed signs of irreversible brain damage. In view of this poor prognosis the therapeutic measures were limited. The patient died on day 24 after admission to the intensive care unit. The case study shows that antifungal treatment should definitely be considered in the context of sepsis treatment if there is a clinically justified suspicion.The role of the severely altered metabolic situation with massive hyperglycemia and ketoacidosis cannot be finally assessed.

Systemic acidemia impairs cardiac function in critically Ill patients

BACKGROUND

Acidemia, is associated with reduced cardiac function in animals, but no studies showing an effect of acidemia on cardiac function in humans are reported. In the present study, we examined the effect of acidemia on cardiac function assessed with transpulmonary thermodilution technique with integrated pulse contour analysis (Pulse Contour Cardiac Output, PiCCO™) in a large cohort of critically ill patients.

METHODS

This was a prospective multicenter observational cross-sectional study of 297 patients from 6 intensive care units in London, England selected from all patients admitted consecutively between May 2018 and March 2019. Measurements of lowest plasma pH and concurrent assessment of cardiac function were obtained.

FINDINGS

There was a significant difference between two pH categories (pH ≤ 7.28 vs. pH > 7.28) for the following variables of cardiac function: SVI (difference in means 32.7; 95% CI: 21 to 45 mL/m2; p < 0.001); GEF (18; 95% CI: 11 to 26%; p < 0.001), dPmax (-331; 95% CI: -510 to -153 mmHg/s; p = 0.001), CFI (0.7; 95% CI: 0.2 to 1.3 1/min; p = 0.01) and CPI (0.09; 95% CI: 0.03 to 0.15 W/m2; p < 0.001). However, there was no significant difference in CI (0.13; 95% CI: -0.20 to 0.47 L/min/m2; p = 0.12) between the pH categories. Also, a significant relationship was found between the quantitative pH and the following variables: SVI (132; 95% CI: 77 to 188 mL/m2; p < 0.001), GEF (74.7; 95% CI: 37.1 to 112.4%; p < 0.001), dPmax (-1587; 95% CI: -2361 to -815 mmHg/s; p < 0.001), CFI (3.5; 95% CI: 0.9 to 6.1 /min; p = 0.009), CPI (0.62; 95% CI: 0.36 to 0.88 W/m2; p < 0.001) and CI (regression coefficient 1.96; 95% CI:0.45 to 3.47 L/min/m2; p = 0.01).

INTERPRETATION

Acidemia is associated with impaired cardiac function in seriously ill patients hospitalized in the intensive care unit supporting the potential value of early diagnosis and improvement of arterial pH in these patients.

FUNDING

The study was partially supported by unrestricted funds from the UCLA School of Medicine.

B-Lines for the assessment of extravascular lung water: Just focused or semi-quantitative?

BACKGROUND

B-lines as typical artefacts of lung ultrasound are considered as surrogate measurement for extravascular lung water. However, B-lines develop in the sub-pleural space and do not allow assessment of the whole lung. Here, we present data from the first observational multi-centre study focusing on the correlation between a B-lines score and extravascular lung water in critically ill patients suffering from a variety of diseases.

PATIENTS AND METHODS

In 184 adult patients, 443 measurements were obtained. B-lines were counted and expressed in a score which was compared to extravascular lung water, measured by single-indicator transpulmonary thermodilution. Appropriate correlation coefficients were calculated and receiver operating characteristics (ROC-) curves were plotted.

RESULTS

Overall, B-lines score was correlated with body weight-indexed extravascular lung water characterized by r = .59. The subgroup analysis revealed a correlation coefficient in patients without an infection of r = .44, in those with a pulmonary infection of r = .75 and in those with an abdominal infection of r = .23, respectively. Using ROC-analysis the sensitivity and specificity of B-lines for detecting an increased extravascular lung water (>10 mL/kg) was 63% and 79%, respectively. In patients with a P/F ratio <200 mm Hg, sensitivity and specificity to predict an increased extravascular lung water was 71% and 93%, respectively.

CONCLUSIONS

Assessment of B-lines does not accurately reflect actual extravascular lung water. In presence of an impaired oxygenation, B-lines may reliably indicate increased extravascular lung water as cause of the oxygenation disorders.

[Uncertain Acute Hemodynamic Instability after Severe Burn Injury: an (Un-)Usual Complication]

First aid and treatment of burn patients pose a challenge to responsible physicians. Primary assessment should include an evaluation of the degree and extent of the burn injuries as well as a physical examination for other trauma injuries and trauma caused by the inhalation of toxic agents. One should focus on removal of the burning source, preservation of body temperature, sterile coverage of the burnt areas, pain management and sufficient hemodynamic stabilization. Grade IIb and more severe burns are most likely subject to surgical intervention to assure sufficient healing. Our case report illustrates a burn patient's initial treatment and clinical course, which includes the development of an acute pulmonary embolism with severe hemodynamic instability. As other critically ill patients, burn patients are at particular risk for complications like infections or other causes for hemodynamic instability. Every cardiovascular event is possibly suspicious for acute pulmonary arterial embolism (PAE). A high or increasing gap between expiratory and arterial CO₂ tension accompanied by typical symptoms like tachycardia and hypotension or respiratory distress may be caused by PAE. An echocardiogram can provide information about possible pathophysiological changes typical for PAE, nevertheless, CT-angiography is today's clinical gold standard for the diagnosis of PAE. As therapeutic measures, heparin should be administered, and thrombolysis should be considered in case of persisting hemodynamic instability, attentively taking possible contraindications into account.

Impact of blunt chest trauma on outcome after traumatic brain injury- a matched-pair analysis of the TraumaRegister DGU®

Background

Traumatic brain injury (TBI) is associated with high rates of long-term disability and mortality. Our aim was to investigate the effects of thoracic trauma on the in-hospital course and outcome of patients with TBI.

Methods

We performed a matched pair analysis of the multicenter trauma database TraumaRegisterDGU® (TR-DGU) in the 5-year period from 2012 to 2016. We included adult patients (≥18 years of age) with moderate to severe TBI (abbreviated injury scale (AIS)= 3–5). Patients with isolated TBI (group 1) were compared to patients with TBI and varying degrees of additional blunt thoracic trauma (AIS_Thorax= 2–5) (group 2). Matching criteria were gender, age, severity of TBI, initial GCS and presence/absence of shock. The χ²-test was used for comparing categorical variables and the Mann-Whitney-U-test was chosen for continuous parameters. Statistical significance was defined by a p-value < 0.05.

Results

A total of 5414 matched pairs (10,828 patients) were included. The presence of additional thoracic injuries in patients with TBI was associated with a longer duration of mechanical ventilation and a prolonged ICU and hospital length of stay. Additional thoracic trauma was also associated with higher mortality rates. These effects were most pronounced in thoracic AIS subgroups 4 and 5. Additional thoracic trauma, regardless of its severity (AIS_Thorax ≥2) was associated with significantly decreased rates of good neurologic recovery (GOS = 5) after TBI.

Conclusions

Chest trauma in general, regardless of its initial severity (AIS_Thorax= 2–5), is associated with decreased chance of good neurologic recovery after TBI. Affected patients should be considered “at risk” and vigilance for the maintenance of optimal neuro-protective measures should be high.

Continuous lateral rotational therapy in thoracic trauma--A matched pair analysis

INTRODUCTION

Given the lack of reliable evidence on the utility of continuous lateral rotational therapy (CLRT) in chest trauma, we performed a single-centre retrospective matched-pair analysis of patients treated either with CLRT or non-continuous manual turning after blunt thoracic trauma.

METHODS

We included adult patients that were admitted to our level 1 trauma centre from 2010-2014 and presented with severe thoracic injuries (AISThorax ≥3) within 24 h after the injury and required at least 72 h of mechanical ventilation. Patients were either treated with manual turning every 2-4 h or CLRT. To ensure comparable injury severity and a similar risk for posttraumatic respiratory complications, we matched for thoracic injury severity, age, additional injuries (head, abdomen, extremities) and need for massive transfusion.

RESULTS

A total of 22 pairs (n = 44 patients) were successfully matched and analysed. The use of CLRT did not have a statistically significant impact on respiratory function, gas exchange, duration of mechanical ventilation, ICU or hospital length of stay, or overall patient outcomes (e.g. pneumonia, sepsis, ARDS, mortality). During active rotation the level of sedation was lower compared to manual turning (Richmond Agitation Sedation Scale; manual turning: -3.6; CLRT: -4.0; p = 0.01). Patient agitation was noticed more frequently in the CLRT group (manual turning: n = 2 (9%); CLRT: n = 9 (41%); p = 0.02).

DISCUSSION

In this well-matched sample, the use of CLRT did not seem to translate into relevant clinical benefits in patients with thoracic trauma in the setting of modern ICU care with the widespread implementation of lung protective ventilation. However, statistical power and generalisability were limited by the small sample size and single centre design. A large RCT is required to provide conclusive results.

[Role of Procalcitonin as a Sepsis Marker]

Adequate diagnosis and therapy of sepsis is of major prognostic relevance. Besides the gold standard (blood culture diagnostics) biomarkers, e.g. serum procalcitonin (PCT), are clinically increasingly used in the diagnosis and for guiding anti-infective treatment. Recent guidelines recommend early determination of PCT. However, trauma, burns, surgical procedure, and intoxications may significantly impact PCT levels. As a rare cause, PCT producing tumors have been described and may be potentially misleading in the clinical setting. While several other constellations for increased PCT in the absence of sepsis (e.g., trauma, intoxications) have been described, it needs to be summarized that according to currently available data, sensitivity and specificity for PCT for the diagnosis of sepsis in critically ill patients is on average between 70 and 80%. Thus, PCT must be interpreted carefully in the context of medical history, physical examination, and microbiological assessment. However, the existing body of literature emphasizes the value of PCT to shorten the duration of an antibiotic treatment. So far, different cut-off values for PCT for certain infections have been identified. While different treatment algorithms have been studied, PCT-guided treatment not only enables to reduce use of antibiotics but as shown most recently may improve outcome of critically ill patients.

Current clinical use of intravenous fosfomycin in ICU patients in two European countries

PURPOSE

In Europe, intravenous fosfomycin (IV) is used particularly in difficult-to-treat or complex infections, caused by both Gram-positive and Gram-negative pathogens including multidrug-resistant strains. Here, we investigated the efficacy and safety of intravenous fosfomycin under real-life conditions.

METHODS

Prospective, multi-center, and non-interventional study in patients with bacterial infections from 20 intensive care units (ICU) in Germany and Austria (NCT01173575).

RESULTS

Overall, 209 patients were included (77 females, 132 males, mean age: 59 ± 16 years), 194 of which were treated in intensive care (APACHE II score at the beginning of fosfomycin therapy: 23 ± 8). Main indications (± bacteremia or sepsis) were infections of the CNS (21.5%), community- (CAP) and hospital-acquired pneumonia (HAP)/ventilator-associated pneumonia (VAP, 15.3%), bone and joint infections (BJI, 11%), abdominal infections (11%), and bacteremia (10.5%). Most frequently identified pathogens were S. aureus (22.3%), S. epidermidis (14.2%), Enterococcus spp. (10.8%), E. coli (12.3%) and Klebsiella spp. (7.7%). At least one multidrug-resistant (MDR) pathogen was isolated from 51 patients (24.4%). Fosfomycin was administered with an average daily dose of 13.7 ± 3.5 g over 12.4 ± 8.6 days, almost exclusively (99%) in combination with other antibiotics. The overall clinical success was favorable in 81.3% (148/182) of cases, and in 84.8% (39/46) of patients with ≥ 1 MDR pathogen. Noteworthy, 16.3% (34/209) of patients developed at least one, in the majority of cases non-serious, adverse drug reaction during fosfomycin therapy.

CONCLUSION

Our data suggest that IV fosfomycin is an effective and safe combination partner for the treatment of a broad spectrum of severe bacterial infections in critically ill patients.

Successful treatment of abdominal compartment syndrome with chemotherapy in a patient with a newly diagnosed Burkitt lymphoma

Mortality of patients treated on the intensive care unit suffering from cancer is high, especially when admitted with an unknown malignancy. Still, anti-tumor therapy in critically ill patients requiring mechanical ventilation is a clinical challenge. Over the last years, successful chemotherapy has been reported, even in critically ill patients with infections and organ failure. In this report, we present a 42-year old male patient who later was been diagnosed for a highly-malignant lymphoma (Burkitt) developed an abdominal compartment syndrome due to ileus, ascites and progressive intestinal tumor manifestation. During the course, he required mechanical ventilation and developed several organ failures including need for renal replacement therapy. After laparotomy the abdomen was left open and managed by a vacuum dressing. The patient received systemic chemotherapy and broad anti-infective treatment in presence of markedly elevated markers of inflammation. Fortunately, he was successfully weaned from vasopressor and respiratory support. By obtaining negative fluid balances closure of the abdomen succeeded 18 days after laparotomy. The patient was transferred to the normal ward without organ dysfunction on day 27 and discharged home after a second cycle of chemotherapy. In conclusion, aggressive treatment using chemotherapy in critically ill patients with initially unkown malignancy may be successful.

One-year molecular surveillance of carbapenem-susceptible A. baumannii on a German intensive care unit: diversity or clonality

Background

A. baumannii is a common nosocomial pathogen known for its high transmission potential. A high rate of carbapenem-susceptible Acinetobacter calcoaceticus-Acinetobacter baumannii (ACB)-complex in clinical specimens led to the implementation of a pathogen-based surveillance on a 32-bed surgical intensive care unit (SICU) in a German tertiary care centre.

Methods

Between April 2017 and March 2018, ACB-complex isolates with an epidemiological link to the SICU were further assessed. Identification to the species level was carried out using a multiplex PCR targeting the gyrB gene, followed by RAPD, PFGE (ApaI) and whole genome sequencing (WGS, core genome MLST, SeqSphere+ software, Ridom). Additional infection prevention and control (IPC) measures were introduced as follows: epidemiological investigations, hand hygiene training, additional terminal cleaning and disinfection incl. UV-light, screening for carbapenem-susceptible A. baumannii and environmental sampling. Hospital-acquired infections were classified according to the CDC definitions.

Results

Fourty four patients were colonized/infected with one or two (different) carbapenem-susceptible ACB-complex isolates. Fourty three out of 48 isolates were classified as hospital-acquired (detection on or after 3rd day of admission). Nearly all isolates were identified as A. baumannii, only four as A. pittii. Twelve patients developed A. baumannii infections. Genotyping revealed two pulsotype clusters, which were confirmed to be cgMLST clonal cluster type 1770 (n = 8 patients) and type 1769 (n = 12 patients) by WGS. All other isolates were distinct from each other. Nearly all transmission events of the two clonal clusters were confirmed by conventional epidemiology. Transmissions stopped after a period of several months. Environmental sampling revealed a relevant dissemination of A. baumannii, but only a few isolates corresponded to clinical strains. Introduction of the additional screening revealed a significantly earlier detection of carbapenem-susceptible A. baumannii during hospitalization.

Conclusions

A molecular and infection surveillance of ACB-complex based on identification to the species level, classic epidemiology and genotyping revealed simultaneously occurring independent transmission events and clusters of hospital-acquired A. baumannii. This underlines the importance of such an extensive surveillance methodology in IPC programmes also for carbapenem-susceptible A. baumannii.

Reduction of nosocomial bloodstream infections and nosocomial vancomycin-resistant Enterococcus faecium on an intensive care unit after introduction of antiseptic octenidine-based bathing

BACKGROUND

Vancomycin-resistant Enterococcus faecium (VRE) is emerging in German intensive care units (ICUs). On a 32-bed surgical ICU at a university hospital, increasing numbers of nosocomial cases occurred despite enforcement of hand hygiene and environmental disinfection.

AIM

To introduce universal octenidine-based bathing in order to reduce the burden of VRE.

METHODS

Between January 2012 and March 2014, patients were screened for VRE on admission and twice weekly. Active surveillance was undertaken for VRE infections and colonizations, and for bloodstream infections (BSI) with any pathogen. Intervention in this before-after study comprised of standardized octenidine-based bathing. Distinct subgroups of VRE colonizations or infections were defined and used for statistical analysis of frequency, prevalence and incidence density.

FINDINGS

In the pre-intervention period (January 2012 to April 2013), the admission prevalence of VRE was 4/100 patients and the mean incidence density of nosocomial cases was 7.55/1000 patient-days (PD). Pulsed-field gel electrophoresis analysis revealed prevalence of three vanA and two vanB clusters. In the post-intervention period (August 2013 to March 2014), the admission prevalence of VRE was 2.41/100 patients and the mean incidence density of nosocomial cases was 2.61/1000 PD [P = 0.001 (pre- vs post-intervention)]. Thirteen nosocomial VRE infections were identified in the pre-intervention period, compared with one nosocomial VRE infection in the post-intervention period. Incidence densities of BSI pre- and post-intervention were 2.98 and 2.06/1000 PD (P = 0.15), respectively.

CONCLUSION

The epidemiology of emerging VRE appeared as a complex mix of admitted cases and transmissions in small clusters, challenging infection control measures. The implementation of universal octenidine-based bathing combined with a standardized washing regime led to a significant reduction in nosocomial VRE.

Assessment of lung edema during ex-vivo lung perfusion by single transpulmonary thermodilution: A preliminary study in humans

BACKGROUND

Single transpulmonary thermodilution (SD) with extravascular lung water index (EVLWI) could become a new tool to better assess lung graft edema during ex-vivo lung perfusion (EVLP). In this study we compare EVLWI with conventional methods to better select lungs during EVLP and to predict post-transplant primary graft dysfunction (PGD).

METHODS

We measured EVLWI, arterial oxygen/fraction of inspired oxygen (P/F) ratio, and static lung compliance (SLC) during EVLP in an observational study. At the end of EVLP, grafts were accepted or rejected according to a standardized protocol blinded to EVLWI results. We compared the respective ability of EVLWI, P/F, and SLC to predict PGD. Mann-Whitney U-test, Fisher's exact test, and receiver-operating characteristic (ROC) curve data were used for analysis. p < 0.05 was considered statistically significant.

RESULTS

Thirty-five lungs were evaluated by SD during EVLP. Three lungs were rejected for pulmonary edema. Thirty-two patients were transplanted, 8 patients developed Grade 2 or 3 PGD, and 24 patients developed Grade 0 or 1 PGD. In contrast to P/F ratio, SLC, and pulmonary artery pressure, EVLWI differed between these 2 populations (p < 0.001). The area under the ROC for EVLWI assessing Grade 2 or 3 PGD at the end of EVLP was 0.93. Donor lungs with EVLWI >7.5 ml/kg were more likely associated with a higher incidence of Grade 2 or 3 PGD at Day 3.

CONCLUSIONS

Increased EVLWI during EVLP was associated with PGD in recipients.

Comparison of European ICU patients in 2012 (ICON) versus 2002 (SOAP)

PURPOSE

To evaluate differences in the characteristics and outcomes of intensive care unit (ICU) patients over time.

METHODS

We reviewed all epidemiological data, including comorbidities, types and severity of organ failure, interventions, lengths of stay and outcome, for patients from the Sepsis Occurrence in Acutely ill Patients (SOAP) study, an observational study conducted in European intensive care units in 2002, and the Intensive Care Over Nations (ICON) audit, a survey of intensive care unit patients conducted in 2012.

RESULTS

We compared the 3147 patients from the SOAP study with the 4852 patients from the ICON audit admitted to intensive care units in the same countries as those in the SOAP study. The ICON patients were older (62.5 ± 17.0 vs. 60.6 ± 17.4 years) and had higher severity scores than the SOAP patients. The proportion of patients with sepsis at any time during the intensive care unit stay was slightly higher in the ICON study (31.9 vs. 29.6%, p = 0.03). In multilevel analysis, the adjusted odds of ICU mortality were significantly lower for ICON patients than for SOAP patients, particularly in patients with sepsis [OR 0.45 (0.35-0.59), p < 0.001].

CONCLUSIONS

Over the 10-year period between 2002 and 2012, the proportion of patients with sepsis admitted to European ICUs remained relatively stable, but the severity of disease increased. In multilevel analysis, the odds of ICU mortality were lower in our 2012 cohort compared to our 2002 cohort, particularly in patients with sepsis.

Assessment of liver perfusion and function by indocyanine green in the perioperative setting and in critically ill patients

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

Successful treatment of severe Clostridium difficile infection by administration of crushed fidaxomicin via a nasogastric tube in a critically ill patient

OBJECTIVE

To report the successful use of crushed fidaxomicin via a nasogastric tube for treatment of a severe Clostridium difficile infection in a critically ill patient.

DATA SOURCES

Clinical observation of a patient, images of abdominal computed tomography, antimicrobial therapy and course of infection parameters.

DATA EXTRACTION

Relevant information contained in the medical observation of the patient and selection of image and laboratory parameters performed in the patient.

DATA SYNTHESIS

We report a case of a 79-year old patient who developed septic shock with an increasing need for norepinephrine and acute renal failure due to a severe Clostridium difficile infection. Antimicrobial therapy with vancomycin via a nasogastric tube and metronidazole i.v. did not lead to improvement, infection parameters further increased, and the clinical condition became increasingly impaired. After 10 days, antimicrobial therapy was changed to fidaxomicin, crushed and administered via nasogastric tube. Within 24hours, infection parameters decreased. Further diarrhoea ceased and stool samples were negative for Clostridium difficile antigen.

CONCLUSIONS

Our case confirms that administration of fidaxomicin via a nasogastric tube was safe and effective in this patient. Further studies are needed to evaluate the efficacy of this strategy in critically ill patients systematically.

[Bilateral carotid artery dissection in a kite surfer by strangulation with the kite lines]

While a kite surfer was preparing the kite it was caught by a gust of wind, which blew it 10 m into the air and the cords became entangled around the neck of the kite surfer causing strangulation. After admittance to hospital, the diagnostics revealed multiple injuries including a bilateral dissection of the internal carotid arteries, cerebral edema and multiple fractures. As kitesurfing is gaining popularity severe injuries are becoming more frequent. Safety precautions, such as preparing the kite with two persons, wearing safety equipment and using bars with a safety leash can prevent severe injuries.

Which score should be used for posttraumatic multiple organ failure? - Comparison of the MODS, Denver- and SOFA- Scores

BACKGROUND

Multiple organ dysfunction and multiple organ failure (MOF) is still a major complication and challenge in the treatment of severely injured patients. The incidence varies decisively in current studies, which complicates the comparability regarding risk factors, treatment recommendations and patients' outcome. Therefore, we analysed how the currently used scoring systems, the MODS, Denver- and SOFA Score, influence the definition and compared the scores' predictive ability.

METHODS

Out of datasets of severely injured patients (ISS ≥ 16, Age ≥ 16) staying more tha 48 h on the ICU, the scores were calculated, respectively. The scores' predictive ability on day three after trauma for resource requiring measurements and patient specific outcomes were compared using receiver-operating characteristics.

RESULTS

One hundred seventy-six patients with a mean ISS 28 ± 13 could be included. MODS and SOFA score defined the incidence of MOF consistently (46.5 % vs. 52.3 %), while the Denver score defined MOF in 22.2 %. The MODS outperformed Denver- and SOFA score in predicting mortality (area under the curve/AUC: 0.83 vs. 0.67 vs. 0.72), but was inferior predicting the length of stay (AUC 0.71 vs.0.80 vs.0.82) and a prolonged time on mechanical ventilation (AUC 0.75 vs. 0.81 vs. 0.84). MODS and SOFA score were comparably sensitive and the Denver score more specific in all analyses.

CONCLUSIONS

All three scores have a comparable ability to predict the outcome in trauma patients including patients with severe traumatic brain injury (TBI). Either score could be favored depending weather a higher sensitivity or specificity is targeted. The SOFA score showed the most balanced relation of sensitivity and specificity. The incidence of posttraumatic MOF relies decisively on the score applied. Therefore harmonizing the competing scores and definitions is desirable.

Comparison of PulsioFlex® uncalibrated pulse contour method and a modified Fick principle with transpulmonary thermodilution measurements in critically ill patients

Monitoring of cardiac index (CI) by uncalibrated pulse contour (PC) methods has been shown to be inaccurate in critically ill patients. We tested accuracy and trending of a new pulse contour method and a modified Fick method using central venous oxygen saturation. We studied 21 critically ill and mechanically ventilated patients (age 20-86 years) monitored by PC (PulsioFlex®) and transpulmonary thermodilution (TPTD, PiCCO2®) as reference. At baseline, reference and PC-derived CI (CIPC) were recorded and CI obtained by Fick's method (FM, CIFICK). After four hours, measurements were performed analogously for trending analysis. CI are given in l/min/m2 as mean±standard deviation. At baseline CITPTD was 3.7±0.7, CIPC 3.8±0.7 and CIFICK 5.2±1.8. After 4 hours, CITPTD was 3.5±0.6, CIPC 3.8±1.2 and CIFICK 4.8±1.7. Mean bias for PC at baseline was -0.1 (limits of agreement [LOA] -1.4 to 1.2) and -0.4 (LOA -2.6 to 1.9) after four hours. Percentage errors (PE) were 34% and 60% respectively. FM revealed a bias of -1.5 (LOA -4.8 to 1.8, PE 74%) at baseline and -1.5 (LOA -4.5 to 1.4, PE 68%) at four hours. With an exclusion window of 10% of mean cardiac index, trending analysis by polar plots showed an angular bias of 5° (radial LOA±57°) for PC and 16° (radial LOA±51°) for FM. Although PC values at baseline were marginally acceptable, both methods fail to yield clinically acceptable absolute values. Likewise, trending ability is not adequate for both methods to be used in critically ill patients.

[The patient with intra-abdominal hypertension]

An intra-abdominal hypertension (IAH) defined as a pathological increase in intra-abdominal pressure (IAP) is commonly found on ICU admission or during the ICU stay. Several studies confirmed that an IAH is an independent predictor for mortality of critically ill patients. The abdominal compartment syndrome (ACS) which is defined as a sustained IAP>20 mmHg (with or without an abdominal perfusion pressure [APP]<60mmHg) that is associated with new organ dysfunction or failure has a mortality of up to 60%. In general, an IAH may be induced by several intra-abdominal as well as extra-abdominal conditions. Reduced abdominal wall compliance, intra-abdominal pathologies (either of the peritoneal space or parenchymateous organs) may lead to an IAH. Most commonly, intra-abdominal infections and/or sepsis and severe trauma or burns are predisposing for an IAH. An early sign may be a decrease in urinary output. The effects of an increased IAP on cardiovascular function are well recognized and include negative effects on preload, afterload and contractility. However, all other compartments of the body may be affected by an IAH. Thus, by an increase of the respective compartment pressure, e.g. intracranial pressure, a poly-compartment syndrome may result. Adequate prevention, a forward-looking strategy, and objective techniques for measurement of IAP are required to avoid or early detect an IAH or ACS. Finally, an immediate and consequent interdisciplinary management using conservative, interventional and operative options are necessary to solve an IAH or ACS.

Evaluation of a transcutaneous method to assess canine liver function by indocyanine green plasma disappearance rate in healthy adult Beagle dogs

A non-invasive, transcutaneous method using near infrared spectroscopy to assess indocyanine green plasma disappearance rate (ICG-PDR) in healthy dogs subjected to different conditions was evaluated in eight healthy purpose-bred Beagles under isoflurane-anaesthesia (Trial 1) and when they had initially recovered from anaesthesia (Trial 2). Plasma ICG concentrations (0, 5, 10, 15, 30 min after rapid ICG injection (0.5 mg/kg) into a peripheral vein were determined by high-performance liquid chromatography in parallel with transcutaneous measurements. ICG clearance (mL/min/kg) and retention rate after 15 min (R15, %) were calculated from plasma concentrations to be 3.09 ± 0.83 (mean ± SD) and 30.6 ± 8.3 in anaesthetised dogs and 3.63 ± 0.88 and 28.1 ± 7.3 in recovering dogs, respectively. ICG-PDR (%/min) and R15 (%) obtained using the transcutaneous method were 7.11 ± 3.18 and 34.6 ± 12.4 (Trial 1) and 7.79 ± 3.33 and 32.3 ± 9.2 (Trial 2). The coefficients of determination (r(2)) for ICG clearance and ICG-PDR were 0.14 (Trial 1) and 0.81 (Trial 2) and 0.47 (Trial 1) and 0.29 (Trial 2) for R15, respectively. The mean bias (lower, upper limit of agreement) for R15 were 5.6 (-12.3, 23.5) (Trial 1) and 3.9 (-12.4, 20.1) (Trial 2). The results suggest good agreement between the two methods in dogs recovering from isoflurane-anaesthesia and the transcutaneous method might be useful in real-time assessment of liver function in conscious dogs.

Hemodynamic Monitoring in the Critically Ill Patient - Current Status and Perspective

In the critically ill patient, early and effective hemodynamic management including fluid therapy and administration of vasoactive drugs to maintain vital organ perfusion and oxygen delivery is mandatory. Understanding the different approaches in the management of critically ill patients during the resuscitation and further management is essential to initiate adequate context- and time-specific interventions. Treatment of hemodynamic variables to achieve a balance between organ oxygen delivery and consumption is the cornerstone. In general, cardiac output is considered a major determinant of oxygen supply and thus its monitoring is regarded helpful. However, indicators of oxygen requirements are equally necessary to assess adequacy of oxygen supply. Currently, more and more less or even totally non-invasive monitoring systems have been developed and clinically introduced, but require validation in this particular patient population. Cardiac output monitors and surrogates of organ oxygenation only enable to adequately guide management, as patient's outcome is determined by acquisition and interpretation of accurate data, and finally suitable management decisions. This mini-review presents the currently available techniques in the field of hemodynamic monitoring in critically ill patients and briefly summarizes their advantages and limitations.

[Neuroleptic malignant syndrome : Rare cause of fever of unknown origin]

Neuroleptic malignant syndrome (NMS) is a possible cause of fever of unknown origin (FUO) and is a potentially fatal adverse effect of various drugs, especially of neuroleptics. First generation antipsychotics, such as received by the patient described in this article, are more likely to cause NMS than second generation antipsychotics. The key symptoms are the development of severe muscle rigidity and elevated temperature associated with the use of neuroleptic medication. Malignant catatonia (MC) is an important differential diagnosis of NMS. While neuroleptics can trigger NMS and must be immediately discontinued if NMS occurs, neuroleptic therapy represents the first line treatment for MC. This article describes the case of a patient with schizoaffective disorder where initially the diagnosis of NMS was not clear. Eventually, fever and a markedly elevated serum creatine kinase (CK) led to the correct diagnosis and the appropriate therapy with dantrolene, bromocriptine and amantadine. Furthermore, a thorough review of the currently available literature on NMS is provided.

Computed tomography for the identification of a potential infectious source in critically ill surgical patients

INTRODUCTION

Computed tomography (CT) seems already to have an important role to identify an infectious source in the management of patients with sepsis. However, our daily clinical behavior in ordering CT imaging was never scrutinized.

METHODS

We conducted a retrospective single-center analysis of CT and its therapeutic consequences in an operative intensive care unit in a tertiary care hospital in Germany. All CTs of the abdomen and/or thorax between 1st January and 31st December 2012 were included. One hundred forty-four CT studies were enrolled: 60.4% visceral, 6.9% vascular, 17.4% thoracic, and 14.6% trauma surgical cases and in 0.7% other disciplines.

RESULTS

In 76 CT studies (52.8%), a source of infection was found and was associated with a change in treatment in 65 (85.5%) cases. In contrast, in patients without identification of an infectious source in the CT imaging, treatment was changed after CT imaging in 11 (16.2%) cases. Computed tomography provided positive findings predominantly in the organ or the region of the surgical field.

CONCLUSIONS

Computed tomographic imaging detected an infectious source in more than 50% of cases. Our data suggest that CT should be recommended to identify a source of infection in critically ill patients. Furthermore, prospective studies are needed to investigate the potential impact of CT imaging on outcome and to define criteria when to perform a CT imaging study.

[Drug interactions in intensive care medicine]

Drug-drug interactions are a common problem in elderly multi-morbid patients receiving polypharmacy. A high quantity of prescribed drugs is associated with an increase in the risk of adverse effects and drug-drug interactions. More and more medical and pharmaceutical stakeholders are involved in the drug therapy of critically ill patients. In the future it will be important to comprehend the medication as a common task. The patient will get the best therapy available, if the cooperation is successful. In general, drug interactions may be related to pharmacokinetic and pharmacodynamic aspects. Pharmacokinetic drug interactions concern the influence of the cytochrome P450 enzymes and transport proteins in the body. Pharmacodynamic interactions can be found, for example, as an additive effect of drugs which are combined. The relevance of both aspects must accordingly be considered and negative impact should be avoided.

Pre-procedure ultrasound increases the success and safety of central venous catheterization†

BACKGROUND

Real-time ultrasound (US) in central venous catheterization is superior to pre-procedure US. However, moving real-time US into routine practice is impeded by its perceived expense and difficulty. Currently, pre-procedure US and landmark (LM) methods are most widely used. We investigated these techniques in internal jugular vein (IJV) catheterization in respect of operator experience, complications, and risk factors.

METHODS

In an observational non-randomized study, we investigated 606 of ∼1300 procedures, that is, 200 patients were treated under pre-procedure US and 406 under LM [pathfinder (PF) n=202, direct cannulation (DC) n=204]. We recorded first needle pass success rate, success rate after the third attempt, and the cannulation time. Procedures were performed by inexperienced (<100) or experienced (>100 catheterizations) operators.

RESULTS

Pre-procedure US was associated with more successful attempts and shorter cannulation times. Under pre-procedure US, 88% of first attempts were successful and 100% of third attempts. The median (range) cannulation time was 39 (10-330) s. Under PF, only 56% of first, and 87% of third, attempts were successful with a median (range) cannulation time of 100 (25-3600) s. Under DC, 61% of first and 89% of third attempts were successful; the median (range) cannulation time was 70 (10-3600) s. Remarkably, inexperienced operators using pre-procedure US (n=38) were significantly faster than experienced operators using PF or DC (n=343) (cannulation time: median 60 s, range 12-330, for inexperienced; 60 s, range 10-3600, for experienced). First puncture success rates were higher (pre-procedure US, inexperienced 84%, PF or DC, experienced 57%).

CONCLUSIONS

Pre-procedure US for IJV catheterization is safe, quick, and superior to LM.

[Penetrating neck injury of a blacksmith by splitter projectile]

Laryngeal injuries are rare but potentially life-threatening injuries. Due to the topography of the neck, accompanying injuries of the greater blood vessels, cervical nerves, thoracic organs and spinal cord are common. Therefore in initial diagnostics, these must be excluded from injuries which determine the prognosis. A patient presented with ventral perforation of the larynx, initial dyspnea, hematemesis and left-sided emphysema of the neck. Cause of the findings, we treated the patient non-operatively in interdisciplinary consensus.

[Case report. Leukocytosis in the course of Clostridium difficile infection]

Clostridium difficile infections (CDI) are increasing in incidence and severity, amongst other reasons because of the increasing spread of hypervirulent strains. Leukocytosis is a sign of severe CDI and is predictive for a complicated course. In this case report, we describe 2 patients with CDI who developed leukocytosis within a leukemoid range. In both cases high white blood cell counts returned totally to normal range under CDI therapy according to guidelines. Leukemia-related therapy patterns were not needed. Notably, in none of the patients a hypervirulent strain was isolated.

The influence of prone positioning on the accuracy of calibrated and uncalibrated pulse contour-derived cardiac index measurements

BACKGROUND

Patients with lung failure who undergo prone positioning often receive extended hemodynamic monitoring. We investigated the influence of modified prone positioning (135°) on the accuracy of pulse contour-derived calibrated cardiac index (CIPC) and uncalibrated cardiac index (CIVIG) in this patient population with transpulmonary thermodilution (TPTD) as reference technique.

METHODS

We studied 16 critically ill and mechanically ventilated patients (11 men, 5 women, aged 20-71 years) with acute lung injury or acute respiratory distress syndrome. Patients were monitored by TPTD with an integrated calibrated pulse contour technique (PiCCO®) and by uncalibrated pulse contour analysis (FloTrac/Vigileo™). Before prone positioning, cardiac index (given in L·min(-1)·m(-2)) was measured by TPTD (CITPTD) and CIPC was calibrated. After positioning, CIPC and CIVIG were read from the monitor and CITPTD was measured. After 8 to 10 hours, prone positioning was completed and measurements were performed analogously. Bland-Altman analysis based on a random-effects model was used to calculate limits of agreement (LOA) and percentage errors. Polar plots were used for trend analysis.

RESULTS

Supine CITPTD was 3.3 ± 0.9 (mean ± SD) and CIVIG was 3.1 ± 0.8. After proning, CIPC was 3.5 ± 0.8, CIVIG 3.3 ± 0.8, and CITPTD 3.6 ± 0.8. Before repositioning, CITPTD was 3.5 ± 0.7 and CIVIG 3.3 ± 1.0. After repositioning, CITPTD was 3.1 ± 0.7, CIPC 3.3 ± 0.7, and CIVIG 2.9 ± 0.6. Mean bias pooled for proning and repositioning was -0.1 (LOA -0.7 to 0.6) for CIPC (percentage error 19%) and 0.3 (LOA -1.3 to 1.9) for CIVIG (percentage error 48%). Changes in CI were too small for trending analysis.

CONCLUSION

Although calibrated CI measurements are only marginally influenced by prone positioning, according to the criteria of Critchley and Critchley, uncalibrated CI values show a degree of error, too high to be considered clinically acceptable.

Extravascular lung water in ARDS patients

Acute respiratory distress syndrome (ARDS) is a common entity in critical care medicine and associated with many diagnoses, including trauma and sepsis, which may lead to multiple organ failure and death. Pathophysiologically, increased capillary permeability is the hallmark of ARDS which is characterized by damage of the capillary endothelium and alveolar epithelium in association with impaired fluid removal from the alveolar space and the accumulation of protein-rich fluid inside the alveoli. The clinical management of patients with ARDS is even more difficult, because in the presence of capillary leakage in the lungs, adequate intravascular volume and cardiac preload are required to maintain organ perfusion. The amount of pulmonary edema fluid is, however, difficult to determine at the bedside. Pulmonary edema can be detected on physical examination and may be confirmed by chest radiography. However, it has been shown to be difficult to quantify the extent of pulmonary edema based on chest radiography or other non-invasive measures. The transpulmonary thermo-dye dilution technique has been introduced as an instrument to quantify the fluid in the pulmonary capillary bed, i.e., extravascular lung water (EVLW). This technique has shown to be potentially valuable in the management of critically ill patients and has been further developed to be clinically available nowadays as single transpulmonary thermodilution. The following review deals with the measurement of EVLW and its place in the management of critically ill patients with ARDS.

Unexpected effects on arterial oxygenation during reduction in oxygen flow via a pumpless lung assist system

The authors describe the effect of marked increase in PaO2 in a patient with acute respiratory distress syndrome and treatment by a pumpless extracorporeal lung assist following reduction in oxygen sweep flow.

[Intra-arterial ECG leads of a positive P-wave potential during central venous catheterization]

The application of a central venous catheter (CVC) is a routine procedure in anaesthesia and intensive care medicine. Although the procedure is generally carried out without complications, nevertheless numerous and, in part acute life threatening and lethal complications have been described. The complication rate during placement of a CVC is up to 12%. To ensure the correct position of the catheter, different methods may be used: for example the intravascular feeder of a positive P-wave of the ECG. In the case of a position check via the ECG (α-Card), the catheter's point serves as a unipolar electrode. The intraatrial ECG lead is used as a raised and heightened P-wave potential for the correct catheter position. In this case, we present a 65 year-old critically ill patient with an occlusion of the right superficial femoral artery and acute respiratory distress syndrome (ARDS) in whom a puncture trial of the right internal jugular vein was carried out. This was followed by the placement of the CVC intended for the right internal jugular vein which, however, turned out to be a direct puncture of the right carotid artery. Despite the inaccurate intra-arterial position, forwarding of the catheter showed a typical raised and heightened P-wave potential. The artery puncture was checked via a blood gas analysis and the artery blood pressure diagram tracing. The removal and correct placement of the CVC were achieved without any problems. These findings emphasize the P-wave potential in the ECG feeder does not correlate with the transition from the superior vena cava to the right atrium. Consequently, this does not preclude an intra-arterial malposition.