Comparison of an advanced minimally invasive cardiac output monitoring with a continuous invasive cardiac output monitoring during lung transplantation.

The aim of this study was to compare a continuous non-calibrated left heart cardiac index (CI) measurement by arterial waveform analysis (FloTrac(®)/Vigileo(®)) with a continuous calibrated right heart CI measurement by pulmonary artery thermodilution (CCOmbo-PAC(®)/Vigilance II(®)) for hemodynamic monitoring during lung transplantation. CI was measured simultaneously by both techniques in 13 consecutive lung transplants (n = 4 single-lung transplants, n = 9 sequential double-lung transplants) at distinct time points perioperatively. Linear regression analysis and Bland-Altman analysis with percentage error calculation were used for statistical comparison of CI measurements by both techniques. In this study the FloTrac(®) system underestimated the CI in comparison with the continuous pulmonary arterial thermodilution (p < 0.000). For all measurement pairs we calculated a bias of -0.55 l/min/m(2) with limits of agreement between -2.31 and 1.21 l/min/m(2) and a percentage error of 55 %. The overall correlations before clamping a branch oft the pulmonary artery (percentage error 41 %) and during the clamping periods of a branch oft the pulmonary artery (percentage error 66 %) failed to reached the required percentage error of less than 30 %. We found good agreement of both CI measurements techniques only during the measurement point "15 min after starting the second one-lung ventilation period" (percentage error 30 %). No agreement was found during all other measurement points. This pilot study shows for the first time that the CI of the FloTrac(®) system is not comparable with the continuous pulmonary-artery thermodilution during lung transplantation including the time periods without clamping a branch of the pulmonary artery. Arterial waveform and continuous pulmonary artery thermodilution are, therefore, not interchangeable during these complex operations.

Patient Empowerment Improved Perioperative Quality of Care in Cancer Patients Aged ≥ 65 Years - A Randomized Controlled Trial.

PURPOSE: This randomized controlled, clinical prospective interventional trial was aimed at exploring the effect of patient empowerment on short- and long-term outcomes after major oncologic surgery in elderly cancer patients. METHODS: This trial was performed from February 2011 to January 2014 at two tertiary medical centers in Germany. The study included patients aged 65 years and older undergoing elective surgery for gastro-intestinal, genitourinary, and thoracic cancer. The patients were randomly assigned to the intervention group, i.e. patient empowerment through information booklet and diary keeping, or to the control group, which received standard care. Randomization was done by block randomization in blocks of four in order of enrollment. The primary outcome were 1,postoperative length of hospital stay (LOS) and 2. long-term global health-related quality of life (HRQoL) one year postoperatively. HRQoL was assessed using the EORTC QLQ C30 questionnaire. Secondary outcomes encompassed postoperative stress and complications. Further objectives were the identification of predictors of LOS, and HRQoL at 12 months. RESULTS: Overall 652 patients were included. The mean age was 72 ± 4.9 years, and the majority of patients were male (68.6%, n = 447). The ^median of postoperative length of stay was 9 days (IQR 7-14 day). There were no significant differences between the intervention and the control groups in postoperative LOS (p = 0.99) or global HRQoL after one year (women: p = 0.54, men: p = 0.94). While overall complications and major complications occurred in 74% and 24% of the cases, respectively, frequency and severity of complications did not differ significantly between the groups. Patients in the intervention group reported significantly less postoperative pain (p = 0.03) than the control group. Independent predictors for LOS were identified as severity of surgery, length of anesthesia, major postoperative complications, nutritional state, and pre-operative physical functional capacity measured by the Timed Up and Go-test by multiple robust regressions. CONCLUSION: Patient empowerment through information booklet and diary keeping did not shorten the postoperative LOS in elderly onco-surgical patients, but improved quality of care regarding postoperative pain. Postoperative length of stay is influenced by pre-operative nutritional state, pre-operative functional impairment, severity of surgery, and length of anesthesia. TRIAL REGISTRATION: Clinicaltrials.gov. Identifier NCT01278537.

Major surgical trauma differentially affects T-cells and APC.

Macrophages have been reported to initiate immunosuppression following trauma and hemorrhage, and recent experimental studies suggest a pivotal role of T-cells in maintaining immunosuppression. The aim of the present study was to investigate the interaction of APC and T-cells in humans following major surgery. First, APC and T-cells from 14 surgical patients were isolated, counted and characterized by their specific surface marker profile 2 and 24 h postoperatively. Then, these cells were co-incubated with cells of the other type, which had been isolated pre-operatively. Chemokine secretion from pre-operative cells as measured by enzyme immunoassay served as a bioassay for the function of the stimulating postoperative cells. CD3(+) T-cells and surface marker CD28 were markedly suppressed postoperatively, while CD3(+)CD25(+)CD127(-)Tregs were not suppressed. CD14(+)APC counts were increased with the most significant increase observed in CD14(+)HLA-DR(-) myeloid-derived suppressor cells. In co-cultures, APC showed increased postoperative secretion of TNF-α and IL-6 independently of whether they had been co-incubated with pre- or postoperative T-cells. T-cells incubated with CD14(+) cells 2 h postoperatively secreted diminished amounts of IFN-γ. The results of the study suggest that T-cells play a pivotal role in mediating immunosuppression after major abdominal surgery.

Dehydroepiandrosterone modulates T-cell response after major abdominal surgery.

BACKGROUND: The immune balance controlled by T-helper (Th)1 and Th2 cells is critical in protecting the host from pathogenic invasion, and its imbalance may increase susceptibility to infection in patients undergoing major surgery. The differentiation of naive T cells to Th1 and Th2 cells is largely driven by cytokines. In addition, steroid hormones have been shown to affect Th1/Th2 balance, particularly in autoimmune diseases. The regulation of Th1/Th2 balance in patients undergoing surgery and its potential clinical relevance remain unclear. MATERIALS AND METHODS: Blood samples were obtained from patients both before and 2 h after major abdominal surgery. Peripheral blood mononuclear cells were isolated and cultured in wells coated with either anti-CD3 (direct T-cell stimulation) or phytohemagglutinin (PHA) (indirect T-cell stimulation), with or without 10(-5) M dehydroepiandrosterone (DHEA). The release of interleukin (IL)-2, interferon gamma, and IL-10 was measured by an enzyme-linked immunosorbent assay, and the expression of CD4, CD8, and CD69 was determined by flow cytometry. RESULTS: DHEA decreased the release of IL-2 and IL-10 in directly (anti-CD3) and indirectly (PHA)-stimulated T cells from postoperative samples, whereas the release of interferon gamma in PHA-stimulated T cells was not affected. The distribution of CD4/CD8 was not significantly different after surgery or DHEA. DHEA was associated with a decrease in the expression of the activation marker CD69 on CD4(+) T cells, whereas the activation of CD8(+) T cells remained unchanged. CONCLUSIONS: These results demonstrate that DHEA plays a critical role in controlling Th1/Th2 balance in the immediate postoperative period. Attenuation of both the Th1 and Th2 responses has been suggested to have immunoprotective effects. The role of DHEA in the regulation of Th1/Th2 balance in patients undergoing major abdominal surgery may, therefore, also be of significant clinical relevance and warrants further investigation.

Critical care strategies to improve neurocognitive outcome in thoracic surgery.

PURPOSE OF REVIEW: This review focuses on neurocognitive outcome with respect to potential pathophysiological inflammatory mechanisms of thoracic surgery and one-lung ventilation, risk factors of postoperative delirium and postoperative cognitive dysfunction (POCD) as well as anti-inflammatory strategies. RECENT FINDINGS: Neurocognitive dysfunction is associated with increased mortality and disability. The incidence of postoperative delirium and POCD is often underestimated in the perioperative care setting. Both are threatening complications after major surgery and independently associated with an increased morbidity and mortality. Nevertheless, in thoracic surgery, the clinical relevance of neurocognitive dysfunction is still underestimated. Currently, there has been a growing interest in inflammation as a cause of the pathogenesis of postoperative delirium and POCD. Furthermore, thoracic surgery often requires one-lung ventilation, which is accompanied with important physiological disturbances, and leads to a pulmonary arteriovenous shunt with the decrease of arterial oxygen content and an exaggerated activation of inflammatory processes. As inflammation is involved in brain dysfunction, anti-inflammatory strategies in the perioperative setting seem to be potential neuroprotective targets concerning specially high-risk patients undergoing thoracic surgery under one-lung ventilation. SUMMARY: There is evidence that important key strategies improve neurocognitive outcome after thoracic surgery. This includes adequate risk stratification, the anesthetic management and postoperative critical care strategies.

Computed tomography findings in septic patients with acute respiratory distress syndrome: correlation with survival and pulmonary versus extrapulmonary septic focus.

OBJECTIVE: The objective of this study was to evaluate computed tomography (CT) findings in patients with sepsis with unknown inflammatory focus and acute respiratory distress syndrome. METHODS: Acute respiratory distress syndrome findings on CT of 36 patients with sepsis were graded on a 6-point scale, and the percentage of affected lung was estimated. Resulting CT scores were correlated to intensive care scores and survival. RESULTS: Forty-four percent of the patients died, revealing a significantly higher CT score than survivors (P = 0.01). Survivors showed larger areas of unaffected lung (P < 0.001), whereas patients with fatal outcome had more ground-glass opacities (P = 0.002; sensitivity, 73%; specificity, 57%) and traction bronchiectasis (P = 0.009; sensitivity, 54%; specificity, 68%). Pulmonary findings on CT did not allow discriminating between a pulmonary and extrapulmonary focus. No significant coherence between CT score and intensive care scores could be revealed. CONCLUSIONS: A CT scoring system based on pulmonary findings in patients with sepsis with acute respiratory distress syndrome comprises prognostic implications in terms of the patients' survival.

Predictive ability of the stability and workload index for transfer score to predict unplanned readmissions after ICU discharge.

OBJECTIVE: Unplanned readmission of hospitalized patients to an ICU is associated with an increased mortality and hospital length of stay. The ability to identify patients at risk, who would benefit from prolonged ICU treatment, is limited. The aim of this study is to validate a previously published numerical index named the Stability and Workload Index for Transfer in a heterogeneous group of ICU patients. DESIGN: In this retrospective data analysis, the Stability and Workload Index for Transfer score was calculated for all patients, and the ability of the score to predict readmission was compared with the original publication. SETTING: Four ICUs, one intermediate care unit, and one postanesthesia care unit of the department of anesthesia and intensive care of a university hospital. PATIENTS: All consecutive patients treated in one of the units. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Unplanned ICU readmissions or unexpected death within 7 days of ICU discharge. The data of 7,175 patients were included in the analysis. Five hundred ninety-six patients were readmitted or died within 7 days of discharge. The patients who are readmitted to the ICU are significantly older and have significantly higher scores that define the severity of disease at the time of admission and discharge of their first ICU stay. The source of admission for the initial ICU stay did not differ (p = 0.055), and the last Glasgow Coma Scale and the last PaO2/FIO2 ratio before discharge from the ICU were higher in patients who did not need a readmission to the ICU. The performance of the Stability and Workload Index for Transfer score is poor with an area under the receiver operator curve of 0.581 (95% CI, 0.556-0.605; p < 0.001). CONCLUSIONS: Based on the data from our patients, the proposed Stability and Workload Index for Transfer score by Gajic et al is not ideal in aiding the clinician in the decision, if a patient can be discharged safely from the ICU and further research is necessary to define the patients at risk for readmission.

Catecholamine dosing and survival in adult intensive care unit patients.

BACKGROUND: Volume management and vasopressor support remain the gold standard of critical care for patients with shock. However, prolonged therapy with catecholamines in high doses is associated with a negative patient outcome. The aim of the present study was to analyze the administered levels of catecholamines over time with respect to survival, and to identify a cut-off to allow a prediction of survival. METHODS: Consecutively, 9,108 adult patients during 22 months were evaluated. This group included 1,543 patients treated with epinephrine and/or norepinephrine with any dose at any time. Time and dosages of the applied drugs, the sequential organ failure assessment and acute and chronic health evaluation II scores on admission and daily, the length of intensive care unit stay, and the outcomes were recorded. RESULTS: The non-survivors received higher doses of norepinephrine and epinephrine than the survivors (p < 0.001). The receiver operator characteristic curve for the area under the curve with non-survival as the classifier revealed a cut-off level of 294.33 µg/kg for norepinephrine with a sensitivity of 74.73 % and a specificity of 70.48 % and a cut-off for epinephrine of 70.36 µg/kg with a sensitivity of 83.87 % and a specificity of 72.79 %. Dose-dependent time curves using these cut-off values were calculated. CONCLUSIONS: Survival of patients with prolonged therapy with norepinephrine and epinephrine above the evaluated thresholds is poor, whereas short-term application of high-dose catecholamines is not associated with poor outcome. Therefore, it remains for the individual clinician, patients, and their surrogates to decide whether the use of high doses of vasopressors is appropriate in view of the low probability of survival.

[Which kind of therapy for which patient? Choosing the ventilator strategy in ARDS]. / Lungenersatzverfahren - Welche Therapie für welchen Patienten? Wahl der Beatmungsstrategie im akuten Lungenversagen.

Ventilator-induced lung injury (VILI) contributes to the high mortality of ALI/ARDS. Lung protective ventilation with a tidal volume of 6 ml / kgIBW (Ideal Body Weight) and a plateau pressure <30 cm H2O has shown to reduce mortality and was thus selected as one of ten quality indicators for critical care in Germany. The optimal level of PEEP is currently unclear; however, patients with severe disorders of gas exchange seem to benefit from higher PEEP levels.Adjusting the respirator settings to the mechanical properties of the individual patient will change the treatment of ARDS in the next few years. Measurements of transpulmonary pressure by an oesophageal probe or electrical impedance tomography (EIT) are promising approaches, but still need to proof their superiority. Until then, every clinician must aim to translate the recommendations of lung protective ventilation into daily practice.

Advances in therapy for acute lung injury.

Despite advances in the therapy for acute lung injury and adult respiratory distress syndrome, mortality remains high. The iatrogenic risk of ventilator-induced lung injury might contribute to this high mortality because the lungs are hyperinflated. Low tidal volume and inspiratory pressure are surrogates for the stress and strain concept; but lung compliance, transpulmonary pressure, and chest wall elastance might differ in individual patients. In previous published studies, an increasing number of patients were treated successfully with extracorporeal support. Extracorporeal membrane oxygenation and interventional lung assist allow ultraprotective ventilation strategies. However, these assists have different technical aspects and different indications.