[Intensive insulin therapy in critically ill patients--contra].
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Blood Glucose↗
Biomedical subjects
K Reinhart
Publications and source records attributed to K Reinhart.
[Sepsis. Update on pathophysiology, diagnostics and therapy].
Sepsis results from the host response to infection. While a localized and controlled inflammatory reaction helps to control infection, a dysregulated response may lead to multiple organ failure and determines the course and prognosis of the septic patient. Despite intensive care, mortality remains as high as 54% for severe sepsis and septic shock. As the mechanisms are becoming better defined, interventions aiming to interfere with the host response have been undertaken, largely with disappointing results. Thus, many evidence-based recommendations suggest waiving of resource-consuming interventions. Nevertheless, several seminal studies have indicated that early and systematic supportive therapy according to pathophysiological principles, most notably early goal-directed therapy, low-dose hydrocortisone and activated protein C, can disrupt dysfunctional cascades and can favourably influence the course of the disease. In parallel, efforts to better define nationwide epidemiology and treatment habits for severe sepsis by the German competence network "SepNet" indicate that therapy of severe sepsis is generally in poor compliance with guidelines, while the personal perception of physicians in charge would suggest high rates of adherence. Thus, strategies of change management, such as implementation of sepsis bundles are warranted to achieve a better standard of care toward the aim of the "surviving sepsis campaign", i.e. a reduction of mortality by 25% within the next 5 years.
Animals↗
[Diagnosis and therapy of sepsis. Guidelines of the German Sepsis Society Inc. and the German Interdisciplinary Society for Intensive and Emergency Medicine].
A recent survey conducted by the publicly funded Competence Network Sepsis (SepNet) reveals that severe sepsis and/or septic shock occurs in 75,000 inhabitants (110 out of 100,000) and sepsis in 79,000 inhabitants (116 out of 100,000) in Germany annually. This illness is responsible for approximately 60,000 deaths and ranges as the third most frequent cause of death after acute myocardial infarction. Direct costs for the intensive care of patients with severe sepsis alone amount to approximately 1.77 billion euros, which means that about 30% of the budget in intensive care is used to treat severe sepsis. However, until now German guidelines for the diagnosis and therapy of severe sepsis did not exist. Therefore, the German Sepsis Society initiated the development of guidelines which are based on international recommendations by the International Sepsis Forum (ISF) and the Surviving Sepsis Campaign (SSC) and take into account the structure and organization of the German health care system. Priority was given to the following guideline topics: a) diagnosis, b) prevention, c) causative therapy, d) supportive therapy, e) adjunctive therapy. The guidelines development process was carefully planned and strictly adhered to the requirements of the Working Group of Scientific Medical Societies (AWMF).
Delivery of Health Care, Integrated↗
[Diagnosis and therapy of sepsis].
A recent survey conducted by the publicly funded Competence Network Sepsis (Sep- Net) reveals that severe sepsis and/or septic shock occurs in 75,000 inhabitants (110 out of 100,000) and sepsis in 79,000 inhabitants (116 out of 100,000) in Germany annually. This illness is responsible for approx. 60,000 deaths and ranges as the third most frequent cause of death after acute myocardial infarction. Direct costs for the intensive care of patients with severe sepsis alone amount to approx. 1.77 billion euros, which means that about 30% of the budget in intensive care is used to treat severe sepsis. However, until now German guidelines for the diagnosis and therapy of severe sepsis did not exist. Therefore, the German Sepsis Society initiated the development of guidelines which are based on international recommendations by the International Sepsis Forum (ISF) and the Surviving Sepsis Campaign (SSC) and take into account the structure and organisation of the German health care system. Priority was given to the following guideline topics: a) diagnosis, b) prevention, c) causative therapy, d) supportive therapy, e) adjunctive therapy. The guidelines development process was carefully planned and strictly adhered to according to the requirements of the Working Group of Scientific Medical Societies (AWMF).
Critical Care↗
[Diagnosis and therapy of sepsis: guidelines of the German Sepsis Society Inc. and the German Interdisciplinary Society for Intensive and Emergency Medicine].
A recent survey conducted by the publicly funded Competence Network Sepsis (SepNet) reveals that severe sepsis and/or septic shock occurs in 75,000 inhabitants (110 out of 100,000) and sepsis in 79,000 inhabitants (116 out of 100,000) in Germany annually. This illness is responsible for approximately 60,000 deaths and ranges as the third most frequent cause of death after acute myocardial infarction. Direct costs for the intensive care of patients with severe sepsis alone amount to approximately 1.77 billion euros, which means that about 30% of the budget in intensive care is used to treat severe sepsis. However, until now German guidelines for the diagnosis and therapy of severe sepsis did not exist. Therefore, the German Sepsis Society initiated the development of guidelines which are based on international recommendations by the International Sepsis Forum (ISF) and the Surviving Sepsis Campaign (SSC) and take into account the structure and organization of the German health care system. Priority was given to the following guideline topics: a) diagnosis, b) prevention, c) causative therapy, d) supportive therapy, e) adjunctive therapy. The guidelines development process was carefully planned and strictly adhered to the requirements of the Working Group of Scientific Medical Societies (AWMF).
Anti-Bacterial Agents↗
Transcriptomic and proteomic patterns of systemic inflammation in on-pump and off-pump coronary artery bypass grafting.
BACKGROUND: Coronary artery bypass grafting (CABG) using cardiopulmonary bypass (CPB) provides controlled operative conditions but induces a whole-body inflammatory response capable of initiating devastating morbidity and mortality. Although technically more demanding, deliberate avoidance of CPB in off-pump surgery attenuates the physiological insult associated with CABG. METHODS AND RESULTS: To systematically assess the molecular mechanisms underlying the better-preserved remote organ function, we studied gene expression patterns in leukocytes and plasma proteomic response to on-pump and off-pump CABG. Proteomic analysis confirmed (tumor necrosis factor-alpha, interleukin [IL]-6, IL-10) and expanded (eg, interferon [IFN]-gamma, granulocyte colony-stimulating factor [G-CSF], monocyte chemotactic protein-1, macrophage inflammatory protein-1beta) the mediators released on CPB, whereas blood leukocyte transcriptomics suggested that circulating leukocytes are not primarily responsible for this response. Interestingly, release of some cytokines (eg, IL-6, IFN-gamma, G-CSF) was observed on off-pump surgery to a similar extent but with delayed kinetics. A total of 45 of 4868 transcripts were identified to be significantly altered as a result of initiation of CPB. Systematic analysis of transcriptional activation by CPB revealed primarily genes involved in inflammation-related cell-cell communication (such as L-selectin or intercellular adhesion molecule-2) and signaling (such as IL-1, IL-8, or IL-18 receptors and toll-like receptors 4, 5, and 6), thus confirming a "primed" phenotype of circulating peripheral blood mononuclear cells. CONCLUSIONS: Gene array and multiplex protein analysis, only in concert, can illuminate the molecular mechanisms responsible for systemic sequelae of CPB and indicate that circulating leukocytes overexpress adhesion and signaling factors after contact with CPB, which potentially facilitates their trapping, eg, in the lungs and may promote a subsequent tissue-associated inflammatory response.
Animals↗
[New approaches to intensive care for sepsis].
In Germany, the mortality from sepsis remains high, and up to 60,000 patients die from it each year. Thus, sepsis is the third most common cause of death. More deaths occur only from coronary heart disease and acute myocardial infarction. In the last 3-4 years, substantial progress in sepsis therapy has been made. Based on these achievements, there is hope of reducing sepsis mortality by 25% in the next few years. Implementing new medical evidence in this context into daily clinical intensive care remains a major hurdle. The early diagnosis of sepsis prior to the onset of clinical deterioration is of particular interest, because this would increase the possibility of early and specified treatment, which is in turn the major determining factor of mortality in septic patients.
Cause of Death↗
[Sepsis -- a disease with many challenges].
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Humans↗
[The value of central venous O(2) saturation for assessment of tissue oxygenation].
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Extracorporeal Membrane Oxygenation↗
[Genuine progress in intensive care medicine must be payable also in future--a plea for a public debate].
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Costs and Cost Analysis↗
[On the use of ultrasound to assist central vein cannulation in Germany: a surgery of 817 departments of anesthesia].
OBJECTIVE AND METHODS: A survey on the current practice in using portable ultrasound machines to assist central vein cannulation was performed by sending a questionnaire to 817 departments of anaesthesiology and intensive care medicine in Germany. Also, incomplete questionnaires were included in the analysis. RESULTS: There was a 54 % response rate. Ultrasound guidance is used by 83 (18.7 %) departments for central vein cannulation. Of these, only 7 (8.4 %) use it routinely and 43 (51.8 %) use it when faced with a difficult vein cannulation. Only one third of the departments with ultrasound facilities are using it optimally, e. g. cannulation under ultrasound guidance. Of those units not using ultrasound for central vein cannulation, 136 (37.7 %) said it was because of lack of equipment and 199 (55.1 %) did not think that it was necessary. CONCLUSION: In Germany, placement of central venous catheters is usually based on anatomical landmarks. Every anaesthetist and intensive care physician should be able to place central venous catheters without an ultrasound device. Still there is not a doubt that ultrasound assistance is useful for beginners, in children, and when blind cannulation fails. Also in patients in whom catheterisation is likely to be difficult (e. g. patients, with previous central venous catheters, with abnormal anatomy etc.) Due to our data a promotion of ultrasound assistance seems urgently required.
Anesthesia↗
The use and safety of transoesophageal echocardiography in the general ICU -- a minireview.
BACKGROUND: The efficacy of transoesophageal echocardiography (TEE) has been evaluated predominantly in medical and cardiac surgical ICUs. This article reviews the pertinent literature and evaluates the impact of TEE in a general surgical ICU. METHODS: Twenty studies on TEE in the ICU were evaluated for complications, indications, diagnostic, therapeutic, and surgical impact on patient management. Diagnostic impact was defined as identification of the underlying cardiovascular pathology, therapeutic impact as changes in patient management and surgical impact as indication for operative procedures. In addition, we reviewed the TEE reports and patient charts of 216 critically ill patients in a 16-bed multidisciplinary surgical ICU at our university hospital, who underwent a TEE for differential diagnosis of hemodynamic instability from July 1995 to December 1998 to assess the impact of TEE on patient management in a general surgical ICU. RESULTS: The diagnostic, therapeutic and surgical impact in a total of 2,508 patients ranged from 44 to 99% (weighted mean 67.2%), 10-69% (36.0%), and 2-29% (14.1%), respectively. The complication rate was 2.6%, with no examination related mortality. In our series in a general surgical ICU, a diagnostic, therapeutic and surgical impact was inferred in 191 (88.4%), 148 (68.5%) and 12 (5.6%) patients, respectively. Adverse effects were observed in 5.6%. CONCLUSION: TEE is safe, well-tolerated and useful in the management of critically ill patients. This applies as well for hemodynamically unstable patients in a general surgical ICU.
Adolescent↗
Equivalence of hydroxyethyl starch HES 130/0. 4 and HES 200/0. 5 for perioperative volume replacement in major gynaecological surgery.
BACKGROUND: Hydroxyethyl starch solutions (HES) are increasingly used for the compensation of surgical blood loss. The objective of this clinical trial was to compare a novel 6% HES 130/0.4 solution with a favourable pharmacological profile and a standard 6% HES 200/0.5 solution for maintenance of haemodynamic stability in major gynaecological surgery. METHODS: Sixty female patients aged 18-80 years undergoing major gynaecological surgery with indication for perioperative colloidal volume replacement were enrolled in this prospective, randomized double-blinded clinical study. The administration of study medication was dependent on individual requirements to maintain haemodynamic stability. The amount of study medication required from induction of anaesthesia until 6 h postoperatively served as the primary investigative parameter. RESULTS: The two one-sided test procedure by Westlake demonstrated equivalence of mean infused volumes between HES 130/0.4 and HES 200/0.5 during the study period (1224 +/- 544 ml and 1389 +/- 610 ml, respectively, P < 0.05). Perioperatively, haemodynamics did not differ significantly between treatment groups. While none of the mean values of coagulation parameters shifted outside the normal range, the degree of haemodilution revealed reduced haematocrit values in HES 200/0.5 treated patients at 6 h postoperatively (P < 0.05). Moreover, prothrombin time (PT) was higher and consequently international normalized ratio (INR) was lower at the same time point for patients who received HES 130/0.4 (P < 0.05). CONCLUSION: This clinical trial demonstrated therapeutic equivalence of this novel low-substituted HES 130/0.4 solution and a standard HES 200/0.5 solution for perioperative volume replacement. Moreover, both HES preparations were equally well-tolerated and safe.
Adult↗
Left ventricular regional wall motion abnormalities during pneumoperitoneum in children.
BACKGROUND: In adult patients, certain levels of PEEP (16 and 20 cm H(2)O) have been associated with left ventricular (LV) regional wall motion abnormalities. Since any increase in intra-abdominal pressure (IAP) exerted by a pneumoperitoneum is transmitted to the intrathoracic cavity, similar effects on LV regional wall motion cannot be ruled out. METHODS: To investigate the effects of pneumoperitoneum on LV regional wall motion, we performed a post hoc analysis of a transoesophageal echocardiography study in eight small children (mean age 3 yr, range 15-63 months) undergoing laparoscopic herniorrhaphy under anaesthesia with sevoflurane in nitrous oxide/oxygen and a PEEP of 5 cm H(2)O. During carbon dioxide insufflation, end-tidal carbon dioxide concentration ()was kept constant by increasing minute volume. RESULTS: An IAP of 12 mm Hg caused significant septal hypokinesia compared with baseline, while anterior and posterior wall motion was not affected. In addition, a lateral hyperkinesia occurred, though this change was not statistically significant. CONCLUSIONS: Pneumoperitoneum may affect LV regional wall motion in paediatric patients undergoing laparoscopic surgery.
Child↗
Intra-atrial ECG is not a reliable method for positioning left internal jugular vein catheters.
BACKGROUND: ECG guidance is widely used for positioning central venous catheters (CVCs) in the superior vena cava. We noticed a higher incidence of a more perpendicular angle between the catheter tip and the vessel wall after left-sided ECG-guided catheter positioning. To investigate the value of left-sided ECG guidance, we performed this prospective study. METHODS: Of 114 patients, 53 were randomized to right and 61 to left internal jugular vein catheterization using a triple lumen catheter. Three methods to ascertain catheter tip position were sequentially applied in each patient, and the insertion depths (ID) obtained using each of the three methods were recorded: (i). ECG guidance with a Seldinger guide wire (ID-A); (ii). ECG guidance with saline 10% used as an exploring electrode (ID-B); (iii). from position ID-B, the catheter was rotated and advanced until all three lumina could be aspirated easily. The catheter was fixed in that position (ID-C). To determine final catheter tip position, intraoperative transoesophageal echocardiography (TOE) and a postoperative chest X-ray (CXR) were performed. RESULTS: The depth of insertion of a catheter using the three methods varied significantly in left-sided (P<0.001), but not in right-sided catheters. Forty-eight of 57 (84%) left-sided CVCs, correctly positioned according to ECG guidance, had to be advanced further to achieve free aspiration through all three lumina. By this stage, five of the catheter tips had been positioned in the upper right atrium as demonstrated by TOE. There were 13 malpositions (23%) after left-sided insertion. In nine catheter malpositions, undetected by ECG guidance, the angle between the catheter tip and the lateral wall of the superior vena cava exceeded 40 degrees on CXR. CONCLUSIONS: Intra-atrial ECG does not detect the junction between the superior vena cava and right atrium. It is not a reliable method for confirming position of left-sided CVCs. Post-procedural CXRs are recommended for left-sided, but not right-sided CVCs.
Aged↗
Left ventricular dysfunction in lethal severe brain injury: impact of transesophageal echocardiography on patient management.
OBJECTIVE: To evaluate the impact of transesophageal echocardiographic (TEE) studies on further patient management and incidence and degree of left ventricular (LV) dysfunction in patients with lethal severe brain injury. DESIGN AND SETTING: Retrospective, clinical study in two surgical intensive care units in a university hospital. PATIENTS: In 51 patients with severe brain injury ultimately leading to brain death, the results of TEE studies were reviewed for evidence of newly developed LV dysfunction (i.e., regional wall motion abnormalities) and its impact on patient management. MEASUREMENTS AND RESULTS: Seven patients (13.7%) had a diminished LV function global (fractional area change <50%). Four of these patients (7.8%) exhibited a severely reduced LV function (fractional area change <35%). Regional wall motion abnormalities and preserved global function were found in eight patients (15.7%). Patient management was altered in all patients with diminished LV function: implementation of advanced hemodynamic monitoring (n=5), institution or adjustment of inotropes and adjustment of fluid management (n=7). In patients exhibiting a severely reduced LV function and deteriorating cardiovascular status, brain death diagnosis was established by one clinical examination in conjunction with laboratory tests, thus shortening the interval required for brain death diagnosis by about 12 h. CONCLUSIONS: Severe LV dysfunction occurred in about 8% of our patients with severe brain injury ultimately leading to brain death. TEE may be helpful in guiding cardiovascular resuscitation ultimately leading to improved organ procurement rates.
Adult↗
[Transesophageal echocardiography and intraoperative management of patients with renal cell carcinoma and rena cava extension].
OBJECTIVE: To evaluate the role of intraoperative real-time transesophageal echocardiography (TEE) for the anesthetic and surgical management of patients with renal cell carcinoma and vena cava extension. METHODS: Retrospective analysis of the intraoperative application of TEE in a series of 4 patients. RESULTS: Real-time TEE with a multiplane probe allowed visualization of inferior vena cava tumor extensions, accurate assessment of the distal extent of vena cava invasion into hepatic veins and right atrium, monitoring of embolism and evaluation of cardiac preload and function in all patients. CONCLUSION: Intraoperative TEE is a useful adjunct to the anesthetic and surgical management of patients with renal cell carcinoma and vena cava extension.
Carcinoma, Renal Cell↗
[Anti-inflammatory treatment in sepsis].
A systemic inflammation with the release of multiple cytokines plays an important role in the pathophysiology of sepsis. During the last years, several anti-inflammatory substances have been investigated with respect to their effects on mortality in patients with sepsis. However, only the antibody fragment of the TNFalpha binding antibody afelimomab and the recombinant human activated protein C (drotrecogin alpha [activated]) were capable of improving the outcome in controlled studies with large sample sizes. The possible administration of these substances should be restricted to patients who meet the inclusion criteria of these studies. In particular, the tight time window, which usually ends 24 h after the onset of sepsis, should be taken into consideration before starting an anti-inflammatory medication. In addition to the anti-inflammatory treatment, the control of the infectious focus and an aggressive hemodynamic stabilization must not be neglected. Ibuprofen, interleukin-1 receptor antagonists and soluble TNFalpha-receptors as well as high dosages of corticosteroids and antithrombin III do not have a place in the anti-inflammatory treatment of sepsis.
Anti-Inflammatory Agents, Non-Steroidal↗