[Individualized use of levosimendan in cardiac surgery]. / Individualisierter Einsatz von Levosimendan in der Herzchirurgie.

BACKGROUND: Levosimendan is a cardiac inotrope that augments myocardial contractility without increasing myocyte oxygen consumption. Additionally, levosimendan has been shown to exhibit anti-inflammatory, antioxidative, and other cardioprotective properties and is approved for treatment of heart failure. Recent studies indicated that these beneficial effects can be achieved with doses lower than the standard dose of 12.5 mg. Patients with preoperatively diagnosed left ventricular ejection fraction (LVEF) ≤40% received 1.25 mg levosimendan after induction of anesthesia. After surgery, administration of low-dose levosimendan was repeated until cardiovascular stability was achieved. OBJECTIVE: This study aimed to evaluate if pharmacological preconditioning with 1.25 mg levosimendan in patients with LVEF ≤40% altered the postoperative need for inotropic agents, the incidence of newly occurring atrial fibrillation, renal replacement therapy, mechanical circulatory support and 30-day mortality. The cumulative dosage of levosimendan was recorded to assess the required dosage in the context of individualized treatment. MATERIAL AND METHODS: This retrospective study included patients with preoperatively diagnosed LVEF ≤40% who underwent cardiac surgery at this institution between January 2015 and December 2018 and who received 1.25 mg levosimendan after induction of anesthesia to prevent postoperative low cardiac output syndrome. Based on echocardiography results, invasive hemodynamic monitoring, and central venous or mixed venous oxygen saturation and lactate clearance, repetitive doses of levosimendan in 1.25 mg increments could be postoperatively administered until cardiovascular stability was achieved. The results were compared to the current literature. RESULTS: We identified 183 patients with LVEF <40% who received pharmacological preconditioning with 1.25 mg levosimendan. Maximum doses of epinephrine, incidence of atrial fibrillation, need for renal replacement therapy and 30-day mortality were found to be below the published rates of comparable patient collectives. In 73.2% of patients, a cumulative dosage of 5 mg levosimendan or less was considered sufficient. CONCLUSION: The presented concept of pharmacological preconditioning with 1.25 mg levosimendan followed by individualized additional dosing in cardiac surgery patients with preoperative LVEF ≤40% suggests that this concept is safe, with possible advantages regarding the need of inotropic agents, renal replacement therapy, and 30-day mortality, compared to the current literature. Individualized treatment with levosimendan to support hemodynamics and a timely reduction of inotropic agents needs further confirmation in randomized trials.

Misleading symptoms and successful noninvasive rewarming of a patient with severe hypothermia (23.1 °C).

Accidental severe hypothermia is a medical emergency in which symptoms may include coma, apnea, pulmonary edema, ventricular dysrhythmia or asystole. Despite optimal treatment, mortality remains high. This article reports a case of severe hypothermia in a geriatric hypothyroid patient, where despite a body core temperature of 23.1 °C the patient presented conscious and with stable vital signs, pronounced motor response, and a Glasgow Coma Scale score of 9. Blood gas analysis (alpha stat at 37 °C) indicated sufficient pulmonary function. A noninvasive rewarming approach proved successful and resulted in discharge without sequelae. This case highlights that symptoms considered pathognomonic for specific stages of hypothermia should be interpreted with great care in clinical practice. Hypothyroidism may have contributed to this uncommon clinical presentation. Body temperature needs to be taken into account when interpreting blood gas analyses. Even at the stage of severe hypothermia, noninvasive forced-air warming enabled rewarming without complications.

[Acute non-allergic angioedema. Rare cause for intensive care unit admission]. / Akutes nichtallergisches Angioödem. Seltene Indikation für eine intensivmedizinische Behandlung.

Angiotensin-converting enzyme (ACE) inhibitor-induced angioedema usually follows an uneventful clinical course; however, if upper airway structures are involved, life-threatening complications may develop. Thus, affected patients should be carefully monitored in an intensive care unit and, if need be, the airway has to be secured early on. This case report discusses diagnostic and therapeutic approaches in a patient with suspected ACE inhibitor-induced angioedema, who had initially been admitted for neoadjuvant radiochemotherapy of rectal cancer.