[Extracorporeal cardiopulmonary resuscitation (eCPR)]

Extracorporeal cardiopulmonary resuscitation (eCPR) is the implementation of extracorporeal membrane oxygenation (ECMO) in selected patients with cardiac arrest and may be considered when conventional CPR efforts fail, as written in the latest international guidelines. eCPR is a complex intervention that requires a highly trained team, specialized equipment, and multidisciplinary support within a healthcare system and it has the risk of several life-threatening complications. However, there are no randomized, controlled studies on eCPR, and valid predictors of benefit and outcome are lacking. Therefore, optimal timing, patient selection, location and method of implementation vary across centers. As utilization of eCPR has increased in recent years and more centers begin to perform eCPR, considerable uncertainties exist in the prehospital setting as well as in the emergency room. However, structured communication and clearly defined processes are essential especially at the interface between prehospital rescue teams and the eCPR team to achieve the highest possible benefit for cardiac arrest patients using eCPR. This article presents an algorithm for structured, evidence-based logistic considerations, patient selection, and implementation of eCPR as well as early care after establishment of extracorporeal life support (ECLS) which are mainly based on the German national recommendations for eCPR of DGIIN, DGK, DGTHG, DGfK, DGNI, DGAI, DIVI and GRC published in 2019 as well as the S3 guideline "Use of extracorporeal circulation (ECLS/ECMO) for cardiac and circulatory failure" and local standard operating procedures of the authors.

Risk Factors for Bleeding Complications after Percutaneous Dilatational Tracheostomy: A Ten-year Institutional Analysis

Summary

Bleeding complications after percutaneous dilatational tracheostomy (PDT) are infrequent but may have a tremendous impact on a patient's further clinical course. Therefore, it seems necessary to perform risk stratification for patients scheduled for PDT. We retrospectively reviewed the records of 1001 patients (46% male, mean age 68.1 years) undergoing PDT (using the Ciaglia Blue Rhino® technique with direct bronchoscopic guidance) in our cardiothoracic ICU between January 2003 and February 2013. Patients were stratified into two groups: patients suffering acute moderate, severe, or major bleeding (Group A) and patients who had no or only mild bleeding (Group B). In the majority of patients, no or only mild bleeding during PDT occurred (none: 425 [42.5%], mild: 488 [48.8%]). In 84 patients (8.4%), bleeding was classified as moderate. Three patients suffered from severe bleeding; only one major bleed with need for emergency surgery occured. Patients in Group A had a significantly higher Simplified Acute Physiology Score on the day of PDT ( P=0.042), higher prevalence of renal replacement therapy on the day of PDT ( P=0.026), higher incidence of coagulopathy ( P=0.043), lower platelet counts ( P=0.037), lower fibrinogen levels ( P=0.012), higher proportion of PDTs performed by residents ( P=0.034) and higher difficulty grading of PDT ( P=0.001). Using logistic regression analyses, difficult PDT, less experienced operator, Simplified Acute Physiology Score >40 and low fibrinogen levels were independent predictors of clinically significant bleeding after PDT.

[Mid-term outcome of cardiac surgery patients with prolonged postoperative intensive care treatment]

BACKGROUND

The number of patients of advanced age and with severe comorbidities undergoing cardiac surgery is rising. Therefore, in addition to the cardiac surgery procedure itself, postoperative intensive care treatment plays an increasingly important role. The mid-term outcome of patients with postoperative long-term stays in intensive care and perioperative risk factors for an adverse outcome have not been sufficiently evaluated.

MATERIAL AND METHODS

All patients who underwent cardiac surgery in our institution between 2000 and 2004 and who required intensive care treatment on our cardiac surgery intensive care unit for at least 1 week were analyzed. Patients who received heart or lung transplantation or surgery for congenital heart failure were excluded. A total of 31 perioperative variables were evaluated for 230 patients. Follow-up was performed 1 year postoperatively.

RESULTS

In all, 4.3% of our patients required a prolonged stay in intensive care following cardiac surgery. Overall 1-year mortality among patients with a long-term stay in intensive care was 26.9%. The logistic regression identified postoperative renal failure requiring dialysis (OR 4.98) as the strongest predictor for mortality within the first year after surgery, followed by postoperative tracheotomy and preoperatively known atrial fibrillation.

CONCLUSION

Mid-term survival among patients who underwent cardiac surgery followed by a complicated postoperative course is encouragingly high. The risk factors identified for an adverse prognosis may be helpful in improving therapy strategies and general therapy decision-making.

Onychomycosis

The guideline on onychomycosis, as passed by the responsible German medical societies, is presented in the present study.

Tinea capitis: ringworm of the scalp

The guideline tinea capitis, as passed by three German medical societies, is presented in the present study.

Dantrolene sodium improves the force-frequency relationship and beta-adregenic responsiveness in failing human myocardium

BACKGROUND

Failing human myocardium is characterized by a negative force-frequency relationship and impaired beta-adrenergic responsiveness which have been related to alterations of the intracellular Ca2+ homeostasis. Dantrolene sodium is a clinically used drug that modulates myocardial [Ca2+]i handling in animal models. This study investigated the effects of dantrolene sodium on intracellular Ca2+ handling and contractile function in failing human myocardium.

METHODS AND RESULTS

Twenty-three muscle strips from human left ventricular trabeculae were obtained from patients undergoing heart transplantation for end-stage heart failure caused by idiopathic dilated cardiomyopathy (n = 15). Isometric contraction and intracellular Ca2+ transients (Ca2+ indicator: aequorin) were recorded simultaneously. The experiments were performed in three separate groups exposed to control condition (n = 8), addition of dantrolene (10 micromol/l; n = 8), or addition of verapamil (1 micromol/l; n = 7). Isoproterenol induced a moderate positive inotropic effect in the control group with a maximal increase of developed tension from 10.8 +/- 2.9 to 23.4 +/- 4.7 mN/mm2 and a parallel rise in peak systolic [Ca2+]i to a maximum of 1.36 +/- 0.20 micromol/l. Dantrolene significantly improved (10.2 +/- 3.8 to 32.4 +/- 0.9 mN/mm2) and verapamil blunted (8.3 +/- 2.8 to 17.1 +/- 4.3 mN/mm2) the inotropic response to isoproterenol. The diastolic and systolic [Ca2+]i during isoproterenol stimulation were slightly lower in the dantrolene group but significantly depressed in the verapamil group as compared to the control group. Similarly, analyses of force-frequency relationships revealed an improvement of developed tension in dantrolene-treated as compared to control preparations whereas the peak systolic [Ca2+]i was almost identical.

CONCLUSION

Dantrolene improves the negative force-frequency relationship and beta-adrenergic responsiveness in failing human myocardium. These effects are not accompanied by an additional increase in intracellular [Ca2+]i but might be related to modifications of the diastolic [Ca2+]i homeostasis.

[Vulvovaginitis circinata in Reiter's disease]

A case of Reiter's disease with circinate vulvovaginitis is presented. As a clinical analogue to circinate balanitis, it should have the same diagnostic value. A combined treatment of prednisone and aromatic retinoid proved to be effective.

[UV light sensitivity of the skin--possibilities and limits of clinical diagnosis]

Our study on 58 test persons showed that the sensitivity of human skin to UV light is independent of the color of skin, hair, eyes or the pigmentation of the mamillae. Therefore, the sensitivity to UV light must be ascertained by subtle phototesting. By means of the new UV phototesting set SBA-LT-400, Saalmann Co., 4900 Herford/West Germany, we determined the minimal erythema doses (MED) of UV-B and UV-A as basic, reproducible parameters regarding Central European people. 7 and 24 hours after radiation, MED showed mean values of 0.032 and 0.037 Joule/cm2, resp., for UV-B, whereas 24.1 and 25.6 Joule/cm2 were measured for UV-A. The pigmentation responses to UV radiation of human skin described in the literature can be reproduced in Mediterranean skin types only.