[Treatment of acute renal failure in Germany: Analysis of current practice]. / Versorgung des akuten Nierenversagens auf deutschen Intensivstationen: Analyse der aktuellen Behandlungspraxis.

BACKGROUND AND OBJECTIVES: There are currently no reliable data on the differential use of renal replacement therapy (RRT) options for critically ill patients with acute renal failure in Germany. PATIENTS AND METHODS: A questionnaire-based survey was delivered to 2265 German intensive care units. The questionnaire contained 19 questions regarding RRT. RESULTS: A total of 423 German intensive care units participated in the survey. The offered modalities of RRT varied significantly: the smaller the facility, the fewer different RRT options were available. Intermittent dialysis procedures were available in only 35% of hospitals with up to 400 beds. In university hospitals, hemodynamically unstable patients were exclusively treated by continuous RRT, whereas in hospitals with up to 400 beds, intermittent RRT was also used. In addition, treatment practice was also dependent on the specialization of the treating physicians: Isolated acute renal failure was treated more often intermittently by nephrologists compared to anesthesiologists (79.7 vs. 43.3%). Nephrologists also used extracorporeal RRT more often in cardiorenal syndrome (54.3 vs. 35.8%), whereas anesthesiologists preferred them in sepsis (37.3 vs. 23.1%). The choice of anticoagulant varied as well: Hospitals with up to 400 beds offered regional citrate anticoagulation in only 50% compared to 90% of university hospitals. CONCLUSIONS: Currently, RRT treatment in acute renal failure on German intensive care units seems to be dependent on the size, local structures, and education of the intensivists rather than patient needs. Our results demonstrate the necessity to establish cross-disciplinary standards for the treatment of acute renal failure in German intensive care units.

[Treatment of acute renal failure in Germany: a structural analysis]. / Versorgung des akuten Nierenversagens in Deutschland--Eine strukturelle Analyse.

INTRODUCTION: There are no reliable data on the structure and practice of the care of critically ill patients with acute renal failure in Germany. METHODS: We carried out a detailed survey by sending a questionnaire to 2265 German Intensive Care Units. The questionnaire contained 19 questions regarding renal replacement therapy. RESULTS: 423 German intensive care units participated in the survey. Most of the ICUs are headed interdisciplinary (47%) or by anesthesiologists (30%), with significant differences depending on the size of the clinic, with primarily interdisciplinary management in smaller clinics. The offered type of renal replacement therapy varies significantly, the smaller the house the fewer methods are available. Thus, intermittent dialysis procedures are offered only in 35% of hospitals with up to 400 beds. The indication for the initiation of acute renal replacement therapy in intensive care is provided predominantly (53%) by an anesthesiologist. A nephrologist is only involved in 22% of all intensive care units. The indication is based primarily on a "clinical criteria", but these are poorly defined. CONCLUSION: Our results demonstrate the need for cross-disciplinary standards for the treatment of acute renal failure in German intensive care units.

[Effectiveness of a hospital-wide educational programme for infection control to reduce the rate of health-care associated infections and related sepsis (ALERTS)--methods and interim results]. / Nutzen eines krankenhausweiten Infektionspräventions-Programmes zur Reduktion nosokomialer Infektionen und assoziierter Sepsisfälle (ALERTS)--Methodik und Zwischenergebnisse.

BACKGROUND AND AIM: Health care associated infections (HAIs) are one of the most frequent complications of hospital care, associated with increased morbidity, mortality and considerable extra costs for the health care system. The overarching objective of the ALERTS study is to demonstrate the feasibility of a hospitalwide programme to reduce the burden of HAIs and related sepsis of at least 20 %. METHODS: Prospective, quasi-experimental study covering all acute care units (27 general wards, 4 ICUs, overall 809 beds) at Jena University Hospital. Surveillance for HAIs is performed by computerized antibiotic monitoring in patients with risk factors for HAIs (i. e. intravenous and urinary catheters, surgery) on a daily basis. Following the first surveillance period a multifaceted, pragmatic infection control programme, aimed at proper hand hygiene and bundles for the prevention of the four most common HAIs will be implemented. Subsequently, a second surveillance period lasting 18 months will be conducted to measure the effect of the infection control programme, starting in May 2013. RESULTS: Interim results for the first surveillance period (09/2011 to 08/2012) are presented. During this period, 30,631 patients were admitted to the participating departments. According to CDC definitions we identified 1,637 HAIs, resulting in an overall incidence of 5.3 %. Based on clinical evaluation only, irrespective of the CDC definitions, an additional 944 HAIs were detected (overall HAI rate, 8.4 % [n =2581]). A substantial proportion of patients had HAI associated severe sepsis or septic shock (lower respiratory tract infection, n = 279 [37 %]; surgical site infection, n = 114 [25 %]; primary sepsis, n = 110 [32 %]; urinary tract infection, n = 46 [8 %]; other, n = 87 [22 %]). CONCLUSION: Our numbers reveal that a high number of HAIs are missed using CDC-definitions and therefore the magnitude of the problem might be underestimated. Furthermore, a high percentage of HAIs progress from localized infection to severe sepsis or septic shock, requiring ICU treatment.

Safety of gelatin for volume resuscitation--a systematic review and meta-analysis.

PURPOSE: Gelatin is frequently used as a volume expander in critical care. Our goal was to investigate its safety. METHODS: Systematic review of randomized controlled trials (RCT) in patients receiving gelatin for resuscitation in comparison to albumin or crystalloids. RESULTS: We identified 40 RCTs published between 1976 and 2010 with 3,275 patients. Median sample size in the gelatin groups was 15 patients (range 10-249). Median gelatin dose was 17 ml/kg (range 6-57 ml/kg). In 32 RCTs (n = 1,946/3,275, 59 % of all patients), the study period was ≤24.0 h. Twenty-nine RCTs (n = 2,001) investigated elective surgical patients, mostly undergoing cardiac surgery (18 RCTs, n = 819). Three RCTs (n = 723) investigated critically ill adults. Two RCTs (n = 59) were performed in emergency room patients, and six RCTs (n = 492) were performed in neonates or children. No study was adequately powered to investigate the frequency of patient-important outcomes. Risks were not statistically significantly different for mortality (RR 1.12, 95 % confidence interval, 0.87-1.44) and exposure to allogeneic transfusion (RR 1.28, 0.89-1.83). On account of only few included studies and the small number of patients, subgroup analyses (high vs. low dose, >24 h vs. shorter periods, and critically ill patients vs. others) were uninformative. Only three RCTs reported the occurrence of acute renal failure. CONCLUSION: Despite over 60 years of clinical practice, the safety and efficacy of gelatin cannot be reliably assessed in at least some settings in which it is currently used. We suggest the need to investigate and establish such safety.

Influence of hemoglobin E trait on the antimalarial effect of artemisinin derivatives.

To determine whether hemoglobin E trait influences the antimalarial effect of artemisinin derivatives, we retrospectively compared 32 case patients with hemoglobin E trait to 32 control patients who did not have hemoglobin E, beta-thalassemia, glucose-6-phosphate dehydrogenase deficiency, or alpha-thalassemia trait on the basis of a mean corpuscular volume > or =78 femtoliters. All patients were admitted to the Hospital for Tropical Diseases in Bangkok, Thailand, with acute falciparum malaria. Control patients were matched to case patients with hemoglobin E trait by treatment with artemisinin derivatives versus other antimalarial drugs, by ethnic group, and by parasite count. Among 38 patients treated with artemisinin derivatives, the presence of hemoglobin E trait was associated with significantly faster parasite clearance (2.9-fold; 95% confidence interval [CI], 1.4-6.3; P=.006). Among 26 patients treated only with other antimalarial drugs, hemoglobin E trait did not significantly enhance parasite clearance (hazards ratio, 1.1; 95% CI, 0.5-2.5; P=. 8). Hemoglobin E trait may potentiate the antimalarial effect of artemisinin derivatives.

Influence of hemoglobin E trait on the severity of Falciparum malaria.

To determine if hemoglobin E trait influences the course of acute malaria, adults hospitalized for the treatment of symptomatic infection with Plasmodium falciparum were studied retrospectively. Forty-two patients with hemoglobin E trait were compared with 175 reference subjects who did not have hemoglobin E, beta-thalassemia, glucose-6-phosphate dehydrogenase deficiency, or alpha-thalassemia. One patient (2.4%) with hemoglobin E trait had a severe complication of malaria by World Health Organization criteria (cerebral malaria), while 32 subjects in the reference group (18.3%) had one or more severe complications: cerebral malaria (n=18), hyperparasitemia (n=16), renal failure (n=10), and severe anemia (n=1) (P=.044 after adjustment for ethnic categories). The estimated odds of severe complications in the reference subjects were 6.9 times the odds in patients with hemoglobin E trait (95% confidence interval, 1.2-146. 4). These results suggest that hemoglobin E trait may ameliorate the course of acute falciparum malaria.

[Intestinal uptake and transfer of zinc after supplement of 2,4-dinitrophenol and ouabain]. / Intestinale Aufnahme und Durchtritt von Zink nach Zulage von 2,4-Dinitrophenol und Ouabain.

The effect of the inhibitors 2,4-dinitrophenol (DNP) and g-strophantin (ouabain) on the intestinal uptake and cellular transfer of zinc (Zn) and the effect of the organic ligands histidine and EDTA were studied in vitro with everted intestinal sacs of normally maintained rats. Zn was added to the incubation solution as ZnCl2 or as ZnCl2 mixed with histidine in a molar ratio of 200 : 1 and mixed with EDTA in a molar ratio of 1 : 1 or 10 : 1. The DNP in a concentrationof 0.05 mM proved sufficient to greatly inhibit the uptake and transfer of Zn from the solution containing ZnCl2 mixed with an excess of histidine. DNP also reduced Zn absorption when ZnCl2 alone as added. On the other hand, the presence of DNP in the solution containing ZnCl2 with EDTA was found to increase the transfer of Zn and its ligand. In the presence of EDTA, Zn absorption may, therefore, be controlled by the uptake and transfer of the ligand. Ouabain at the contration of 5 mM and 10 mM greatly reduced Zn uptake by the intestinal wall and the celluar Zn transfer from the solution containing ZnCl2 and histidine. There was only a small effect of ouabain on Zn absorption whether ZnCl2 is added alone or with EDTA. The addition of an excess of histidine as ligand to ZnCl2 in the control groups markedly improved Zn absorption. In contrast to this, the addition of EDTA to ZnCl2 reduces the intestinal Zn uptake and increases the transfer of Zn compared to ZnCl2 alone.