Perioperative echocardiography-guided hemodynamic therapy in high-risk patients: a practical expert approach of hemodynamically focused echocardiography.

The number of high-risk patients undergoing surgery is growing. To maintain adequate hemodynamic functioning as well as oxygen delivery to the vital organs (DO2) amongst this patient population, a rapid assessment of cardiac functioning is essential for the anesthesiologist. Pinpointing any underlying cardiovascular pathophysiology can be decisive to guide interventions in the intraoperative setting. Various techniques are available to monitor the hemodynamic status of the patient, however due to intrinsic limitations, many of these methods may not be able to directly identify the underlying cause of cardiovascular impairment. Hemodynamic focused echocardiography, as a rapid diagnostic method, offers an excellent opportunity to examine signs of filling impairment, cardiac preload, myocardial contractility and the function of the heart valves. We thus propose a 6-step-echocardiographic approach to assess high-risk patients in order to improve and maintain perioperative DO2. The summary of all echocardiographic based findings allows a differentiated assessment of the patient's cardiovascular function and can thus help guide a (patho)physiological-orientated and individualized hemodynamic therapy.

[Perioperative optimization using hemodynamically focused echocardiography in high-risk patients-A practice guide]. / Perioperative Optimierung mittels auf die Hämodynamik fokussierter Echokardiographie bei Hochrisikopatienten ­ eine Praxisanleitung.

BACKGROUND: The number of high-risk patients undergoing surgery is steadily increasing. In order to maintain and, if necessary, optimize perioperative hemodynamics as well as the oxygen supply to the organs (DO2) in this patient population, a timely assessment of cardiac function and the underlying pathophysiological causes of hemodynamic instability is essential for the anesthesiologist. A variety of hemodynamic monitoring procedures are available for this purpose; however, due to method-immanent limitations they are often not able to directly identify the underlying cause of cardiovascular impairment. OBJECTIVE: To present a stepwise algorithm for a perioperative echocardiography-based hemodynamic optimization in noncardiac surgery high-risk patients. In this context, echocardiography on demand according to international guidelines can be performed under certain conditions (hemodynamic instability, nonresponse to hemodynamic treatment) as well as in the context of a planned intraoperative procedure, mostly as a transesophageal echocardiography. METHODS AND RESULTS: Hemodynamically focused echocardiography as a rapidly available bedside method, enables the timely diagnosis and assessment of cardiac filling obstructions, volume status and volume response, right and left heart function, and the function of the heart valves. CONCLUSION: Integrating all echocardiographic findings in a differentiated assessment of the patient's cardiovascular function enables a (patho)physiologically oriented and individualized hemodynamic treatment.

[Short version of the 2nd edition of the German-Austrian S3 guidelines "Cardiogenic shock complicating myocardial infarction-Diagnosis, monitoring and treatment"]. / Kurzversion der 2. Auflage der deutsch-österreichischen S3-Leitlinie "Infarkt-bedingter Kardiogener Schock ­ Diagnose, Monitoring und Therapie".

BACKGROUND: The present guidelines ( http://leitlinien.net ) focus exclusively on cardiogenic shock due to myocardial infarction (infarction-related cardiogenic shock, ICS). The cardiological/cardiac surgical and the intensive care medicine strategies dealt with in these guidelines are essential to the successful treatment and survival of patients with ICS; however, both European and American guidelines on myocardial infarction and heart failure and also position papers on cardiogenic shock focused mainly on cardiological aspects. METHODS: Evidence on the diagnosis, monitoring and treatment of ICS was collected and recommendations compiled in a nominal group process by delegates of the German Cardiac Society (DGK), the German Society for Medical Intensive Care Medicine and Emergency Medicine (DGIIN), the German Society for Thoracic and Cardiovascular Surgery (DGTHG), the German Society for Anaesthesiology and Intensive Care Medicine (DGAI), the Austrian Society for Internal and General Intensive Care Medicine (ÖGIAIM), the Austrian Cardiology Society (ÖKG), the German Society for Prevention and Rehabilitation of Cardiovascular Diseases (DGPR) and the German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI), under the auspices of the Working Group of the Association of Medical Scientific Societies in Germany (AWMF). If only poor evidence on ICS was available, general study results on intensive care patients were inspected and presented in order to enable analogue conclusions. RESULTS: A total of 95 recommendations, including 2 statements were compiled and based on these 7 algorithms with defined instructions on the course of treatment.

[COVID-19 in old age-The geriatric perspective]. / COVID-19 im Alter ­ Die geriatrische Perspektive.

Predominantly the older population is affected by a severe course of COVID-19. The mortality of hospitalized patients with COVID-19 above the age of 80 years is up to 54% in international studies. These observations indicate the necessity to highlight the geriatric perspective on this disease. The diagnostics and treatment of COVID-19 do not differ between younger and older patients but atypical symptoms should be expected more frequently in old age. Older subjects show an increased need for rehabilitation after COVID-19. Paradoxically, increasing rehabilitation demands go along with a reduced availability of geriatric rehabilitation options, the latter being a consequence of closure or downsizing of rehabilitation departments during the pandemic. In general, measures of isolation and quarantine should be diligently balanced as the health and emotional consequences of such measures may be severe in older persons. In light of the poor prognosis of older COVID-19 patients, advanced care planning becomes even more relevant. Caregivers and physicians should be encouraged to compose advanced care directives that also reflect the specific circumstances of COVID-19. Fortunately, current data suggest that the effectiveness of the vaccination with the mRNA-vaccines approved in Germany may be equally high in older compared to younger persons.

[Abdominal pain and unclear focal liver lesion in 46-year-old female patient]. / Rechtsseitiger Oberbauchschmerz und unklare Leberraumforderung bei einer 46-jährigen Patientin.

A 46-year-old woman presented with recurrent right upper quadrant pain. Abdominal ultrasound revealed an inhomogeneous liver lesion (4â€¯× 7 cm) with complex echotexture. Since further contrast-enhanced imaging tests were inconclusive and lesion integrity remained unclear, a left hemihepatectomy was performed. Histological examination revealed a hepatic epithelioid angiomyolipoma. Hepatic epithelioid angiomyolipoma is a rare, mostly benign, mesenchymal hepatic tumor, composed of smooth muscle cells, adipose tissue, and blood vessels of varying proportions, and its correct diagnosis remains a clinical challenge.

[Angina pectoris in a 47-year-old athletic man with psoriasis vulgaris]. / Pektanginöse Beschwerden bei einem 47-jährigen athletischen Patienten mit Psoriasis vulgaris.

A 47-year-old man presented with angina pectoris complaints in the chest pain unit. Due to psoriasis and psoriatic arthritis he had been systemically treated for 4 years. Because of an increased cardiovascular risk profile, coronary heart disease (CHD) was suspected and an invasive coronary diagnosis was performed. In the cardiac catheterization, CHD could be detected and treated in the same session. The risk of CHD in patients with psoriasis is increased due to a higher incidence of risk factors but also the disease itself. Patients with psoriasis should regularly undergo cardiovascular risk screening.

[Which patients benefit from transport with ongoing cardiopulmonary resuscitation? : Retrospective analysis of 70 patients with refractory preclinical cardiac arrest]. / Welcher Patient profitiert von einem Transport unter laufender kardiopulmonaler Reanimation? : Retrospektive Analyse von 70 Patienten mit refraktärem präklinischem Herzstillstand.

BACKGROUND: Mortality in patients with out-of-hospital cardiac arrest (OHCA) remains very high despite advances in resuscitation algorithms. Most of these patients die at the scene and do not reach hospital. It is currently the subject of discussion whether transport to hospital with ongoing cardiopulmonary resuscitation (CPR) improves survival and neurological outcome in patients with OHCA. OBJECTIVE: The aim of this study was to identify predictors of survival and good neurological outcome in patients after OHCA who were transported to hospital with ongoing CPR. PATIENTS AND METHODS: A total of 70 consecutive patients with refractory OHCA (mean age 54.7 ± 15 years) transported to hospital with ongoing CPR were retrospectively analyzed. Neurological outcome was assessed after 30 days based on the Glasgow-Pittsburgh cerebral performance category (CPC). RESULTS: After 30 days 82.9% of the patients enrolled in the trial died (CPC score of 5), 8 patients (11.4%) showed a good neurological recovery with CPC scores of 1-2 and 4 patients (5.7%) had a poor neurological outcome with CPC scores of 3-4. Predictors of good neurological outcome were witnessed arrest, initial defibrillatable rhythm and serum lactate levels on admission. In all patients with good outcome, the index event for OHCA was from cardiac causes. CONCLUSION: Selected patient collectives can benefit from transport to hospital with ongoing cardiopulmonary resuscitation (CPR).

[Recommendations for extracorporeal cardiopulmonary resuscitation (eCPR) : Consensus statement of DGIIN, DGK, DGTHG, DGfK, DGNI, DGAI, DIVI and GRC]. / Empfehlungen zur extrakorporalen kardiopulmonalen Reanimation (eCPR) : Konsensuspapier der DGIIN, DGK, DGTHG, DGfK, DGNI, DGAI, DIVI und GRC.

Extracorporeal cardiopulmonary resuscitation (eCPR) may be considered as a rescue attempt for highly selected patients with refractory cardiac arrest and potentially reversible etiology. Currently there are no randomized, controlled studies on eCPR, and valid predictors of benefit and outcome which might guide the indication for eCPR are lacking. Currently selection criteria and procedures differ across hospitals and standardized algorithms are lacking. Based on expert opinion, the present consensus statement provides a proposal for a standardized treatment algorithm for eCPR.

[Circulatory failure : Out- and inpatient management]. / Kreislaufschwäche : Ambulantes und stationäres Management.

Circulatory insufficiency is often understood as symptomatic hypotension due to various causes. The clinical result of circulatory dysregulation is arterial hypotension. The manifestation of hypotension is often divided into chronic and acute forms. Chronic hypotension can be distinguished etiopathogenetically into primary and secondary hypotension. Acute hypotension is usually equated to circulatory shock. While patients with chronic hypotension should be seen primarily by their general practitioner, patients with acute hypotension and a frequently severe clinical manifestation should be evaluated in the emergency department or, if there is a specific cause, directly in the acute clinic. Standardization of diagnostic and therapeutic pathways in both out- and inpatient care-not only for the management of circulatory weakness-would be an improvement not only in regards to patient care, but also with respect to healthcare economics.

Our 2015 approach to invasive pulmonary aspergillosis.

At the University Hospital of Cologne, in general two patient groups at high risk for invasive aspergillosis receive posaconazole prophylaxis: Acute myelogenous leukaemia patients during remission induction chemotherapy and allogeneic haematopoietic stem cell transplant recipients. Other patients at risk undergo serum galactomannan testing three times weekly. At 72-96 h of persisting fever despite broad-spectrum antibiotics, or at onset of lower respiratory tract symptoms a thoracic computed tomography (CT) scan is performed. Without lung infiltrates on CT, IPA is ruled out. In lung infiltrates not suggestive for IPA mycological confirmation is pursued. In patients without posaconazole prophylaxis empiric caspofungin will be considered. CT findings typical for IPA prompt targeted treatment, and mycological confirmation. Bronchoalveolar lavage (BAL) is most important for cultural identification and susceptibility testing, and facilitates diagnosing other pathogens. BAL performance is virtually independent of platelet counts. If despite suggestive infiltrates BAL does not yield the diagnosis, CT-guided biopsy follows as soon as platelet counts allow. Surgery can also be beneficial in diagnosis and treatment of IPA. If the diagnosis of IPA is not established, mucormycosis is a valid concern. In patients with breakthrough IPA during posaconazole prophylaxis liposomal amphotericin B is the drug of choice. If no posaconazole prophylaxis was given, voriconazole is the treatment of choice for IPA.

Essential Hypertension: Cardiovascular Response to Breath Hold Combined with Exercise.

Essential hypertension (EH) is a widespread disease and might be prevalent in apnea divers and master athletes. Little is known about the influence of EH and the antihypertensive drugs (AHD) on cardiovascular reactions to combined breath hold (BH) and exercise. In this pilot study, healthy divers (HCON) were compared with treated hypertensive divers with regard to heart rate (HR) and mean blood-pressure (MAP) responses to BH, exercise and the combination of both. Ten subjects with EH and ten healthy divers were tested. 3 different 20 s stimuli were applied: BH combined with 30 W or 150 W and 150 W without BH. The time-charts during the stress intervals and during recovery were compared. Subjects treated with an angiotensin-converting enzyme (ACE) inhibitor showed higher changes for MAP values if breath hold was performed. HR responses were obviously changed if a ß-blocker was part of the medication. One subject showed extreme MAP responses to all stimuli and conspicuous HR if BH was involved. The modulation of HR-/MAP-response in EH subjects depends on the mechanisms of antihypertensive agents. The combination of an ACE inhibitor and a ß-blocker may give the best protection. It is recommended to include short apnea tests in the fitness-to-dive examination to individually predict potential endangerment.

Pharmacokinetics, pharmacodynamics, toxicology and therapeutics of mavacoxib in the dog: a review.

Mavacoxib is a novel nonsteroidal anti-inflammatory drug (NSAID), with a preferential action on the cyclooxygenase (COX)-2 isoform of COX and a long duration of action. It is classified chemically as a member of the sulphonamide subgroup of coxibs. Mavacoxib is highly lipid but very poorly water soluble. In the dog, the pharmacokinetic (PK) profile comprises very slow body clearance, long elimination half-life and a relatively large distribution volume. Biotransformation and renal excretion are very limited, and elimination occurs primarily by biliary secretion and excretion of unchanged drug in faeces. The PK profile of mavacoxib differs quantitatively between young healthy dogs (Beagles and mongrels) and clinical cases with osteoarthritis (OA). In OA dogs, mavacoxib exhibits a much longer terminal half-life, associated principally with their greater median body weight compared with dogs used in preclinical studies. There is also some evidence of breed differences and a small effect of age on mavacoxib PK in the OA canine population. The pharmacodynamics (PD) of mavacoxib has been established: (i) in whole blood assays at the molecular level (inhibition of COX-1 and COX-2 isoforms); (ii) in preclinical models of inflammation and pain; and (iii) in clinical OA subjects treated with mavacoxib. The dosage schedule of mavacoxib for clinical use has been determined by owner and veterinary clinical assessments and is supported by integration of PK and PD preclinical data with clinical responses in canine disease models and in dogs with naturally occurring OA. The dosage regimen has been further confirmed by correlating levels of inhibition of COX isoforms in in vitro whole blood assays with plasma concentrations of mavacoxib achieved in OA dogs. In addition to the specific properties of mavacoxib, some general aspects of the PK and PD of other agents of the NSAID group, together with pathophysiological and clinical aspects of OA, are reviewed, as a basis for correlating with the safety and efficacy of mavacoxib in therapeutic use. Integration of PK and PD data suggests that the recommended dosage regimen of 2 mg/kg bw once for 14 days, followed by administration at monthly intervals, is optimal from both efficacy and safety perspectives and is further confirmed by clinical field studies.

Examining the competitive advantage of Diuraphis noxia (Hemiptera: Aphididae) biotype 2 over biotype 1.

The Russian wheat aphid, Diuraphis noxia (Kurdjumov) is a serious pest of small grains, such as wheat and barley. High population growth rates and a broad gramineae host range have allowed this aphid to successfully establish and become pestiferous across much of North America since its invasion in the mid-1980s. Resistant wheat cultivars were developed and provided control ofD. noxia until 2003, when a new biotype (designated RWA2, as contrasted with the original biotype's designation, RWA1) emerged and rapidly spread through dryland winter wheat-growing regions. RWA2 displaced RWA1 more quickly than expected, based on RWA2's advantage in RWA1-resistant wheat cultivars. Previous research suggested that RWA2 may out-compete RWA1 in cooler temperatures. Thus, we sought to determine if RWA2 had a competitive advantage over RWA1 during the overwintering period. We placed a known distribution of RWA1 and RWA2 aphids in the field for the winter at three sites across a latitudinal gradient (from northern Colorado to Texas) to test for a competitive advantage between these biotypes. We found overwhelming support for an overwintering competitive advantage by RWA2 over RWA1, with evidence suggesting a > 10-fold advantage even at our Texas site (i.e., the site with the mildest winter). This substantial overwintering advantage helps explain the quick dispersion and displacement of RWA1 by RWA2.

[Management of ear, nose and throat emergencies]. / Management von Hals-Nasen-Ohren-Notfällen.

Emergency situations involving the ears, nose, and throat (ENT) area can pose considerable challenges for clinicians and often require an interdisciplinary approach due to the involvement of different organ systems. To avoid damage to highly relevant sensory and perception organs and life-threatening bleeding or respiratory complications, strategies that are as quick and targeted as possible are necessary. This article aims to provide an overview of ENT emergency management strategies. The entire spectrum from simple conservative to highly complex surgical measures plays a role here, both diagnostically and therapeutically. Aspects such as bleeding, respiratory problems, inflammation, hearing disorders, vertigo, facial palsy and injuries to the head and neck area are discussed. In addition, important topics such as preventive measures and possible complications are also addressed to ensure optimal patient care.

Pandemic 2009 influenza A(H1N1) virus infection coinciding with invasive pulmonary aspergillosis in neutropenic patients.

SIn patients receiving anti-neoplastic chemotherapy, the impact of influenza on the incidence of invasive pulmonary aspergillosis (IPA) remains unknown. We matched data of the Cologne Cohort of Neutropenic Patients (CoCoNut) with records from the Institute for Virology and compared the findings to historical data. During the pandemic, we diagnosed influenza A(H1N1) in five patients with malignancies and febrile neutropenia refractory to antibiotic therapy. Probable IPA was diagnosed in three of these patients on the grounds of typical computed tomography morphology and microbiological results. Three of five patients receiving remission-induction chemotherapy for acute myeloid leukaemia developed aspergillosis although receiving posaconazole prophylaxis. In the 3 years before the influenza pandemic, only 2/77 patients of this group developed infection. Infection with influenza A(H1N1) may increase the risk for invasive aspergillosis in neutropenic patients. Pulmonary aspergillosis is an important additional differential diagnosis in neutropenic influenza patients with pneumonia.

[Extracorporeal cardiopulmonary resuscitation (eCPR)]. / Extrakorporale kardiopulmonale Reanimation (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.

Levosimendan in intensive care and emergency medicine: literature update and expert recommendations for optimal efficacy and safety.

The inodilator levosimendan, in clinical use for over two decades, has been the subject of extensive clinical and experimental evaluation in various clinical settings beyond its principal indication in the management of acutely decompensated chronic heart failure. Critical care and emergency medicine applications for levosimendan have included postoperative settings, septic shock, and cardiogenic shock. As the experience in these areas continues to expand, an international task force of experts from 15 countries (Austria, Belgium, China, Croatia, Finland, France, Germany, Greece, Hungary, Italy, the Netherlands, Spain, Sweden, Switzerland, and the USA) reviewed and appraised the latest additions to the database of levosimendan use in critical care, considering all the clinical studies, meta-analyses, and guidelines published from September 2019 to November 2021. Overall, the authors of this opinion paper give levosimendan a "should be considered" recommendation in critical care and emergency medicine settings, with different levels of evidence in postoperative settings, septic shock, weaning from mechanical ventilation, weaning from veno-arterial extracorporeal membrane oxygenation, cardiogenic shock, and Takotsubo syndrome, in all cases when an inodilator is needed to restore acute severely reduced left or right ventricular ejection fraction and overall haemodynamic balance, and also in the presence of renal dysfunction/failure.

[Sonography in intensive care and emergency medicine : A new training concept]. / Sonographie in der internistischen Intensiv- und Notfallmedizin : Ein neues Ausbildungskonzept.

Structured sonography training in internal medicine intensive care and emergency medicine (SIN) comprises two levels and was proposed by three national societies in Germany (DGIIN, DGK and DEGUM). The curriculum consists of a basic level (SIN-I) and an expert level (SIN-II) which are consecutive levels teaching both theoretical and hands-on skills using a symptom-based approach. Competency is assessed using written, oral and practical structured assessments at the end of each level. The goal is to implement national and international recommendations regarding the use of point-of-care ultrasound into clinical practice.

[Focused ultrasound in the emergency room]. / Fokussierte Sonographie im Schockraum.

Ultrasound is an important tool in diagnosis and treatment of critically ill patients. For trauma patients the eFAST (extended focused assessment with sonography for trauma) algorithm is already implemented in the diagnostic pathway. However, critically ill patients without trauma also need a structured approach including an early focused ultrasonographic exam. National and international guidelines regarding critical illnesses such as acute coronary syndrome, cardiogenic shock complicating myocardial infarction, pulmonary embolism or acute aortic syndromes recommend the use of ultrasound. We present pathways how ultrasound can be used in the diagnostic approach of common symptoms such as dyspnea, shock and abdominal pain. Using the ABCDE approach this article shows how ultrasound can be incorporated into the diagnostic pathway.

[Core curriculum Medical intensive care medicine of the German Society of Medical Intensive Care and Emergency Medicine (DGIIN)]. / Curriculum Internistische Intensivmedizin.

Medical intensive care medicine treats patients with severe, potentially life-threatening diseases covering the complete spectrum of internal medicine. The qualification in medical intensive care medicine requires a broad spectrum of knowledge and skills in medical intensive care medicine, but also in the general field of internal medicine. Both sides of the coin must be taken into account, the treatment with life-sustaining strategies of the acute illness of the patient and also the treatment of patient's underlying chronic diseases. The indispensable foundation of medical intensive care medicine as described in this curriculum includes basic knowledge and skills (level of competence I-III) as well as of behavior and attitudes. This curriculum is primarily dedicated to the internist in advanced training in medical intensive care medicine. However, this curriculum also intends to reach trainers in intensive care medicine and also the German physician chambers with their examiners, showing them which knowledge, skills as well as behavior and attitudes should be taught to trainees according to the education criteria of the German Society of Medical Intensive Care and Emergency Medicine (DGIIN).