Intraoperative haemodynamic monitoring and management of adults having non-cardiac surgery: Guidelines of the German Society of Anaesthesiology and Intensive Care Medicine in collaboration with the German Association of the Scientific Medical Societies.

Haemodynamic monitoring and management are cornerstones of perioperative care. The goal of haemodynamic management is to maintain organ function by ensuring adequate perfusion pressure, blood flow, and oxygen delivery. We here present guidelines on "Intraoperative haemodynamic monitoring and management of adults having non-cardiac surgery" that were prepared by 18 experts on behalf of the German Society of Anaesthesiology and Intensive Care Medicine (Deutsche Gesellschaft für Anästhesiologie und lntensivmedizin; DGAI).

Extravascular lung water levels are associated with mortality: a systematic review and meta-analysis.

BACKGROUND: The prognostic value of extravascular lung water (EVLW) measured by transpulmonary thermodilution (TPTD) in critically ill patients is debated. We performed a systematic review and meta-analysis of studies assessing the effects of TPTD-estimated EVLW on mortality in critically ill patients. METHODS: Cohort studies published in English from Embase, MEDLINE, and the Cochrane Database of Systematic Reviews from 1960 to 1 June 2021 were systematically searched. From eligible studies, the values of the odds ratio (OR) of EVLW as a risk factor for mortality, and the value of EVLW in survivors and non-survivors were extracted. Pooled OR were calculated from available studies. Mean differences and standard deviation of the EVLW between survivors and non-survivors were calculated. A random effects model was computed on the weighted mean differences across the two groups to estimate the pooled size effect. Subgroup analyses were performed to explore the possible sources of heterogeneity. RESULTS: Of the 18 studies included (1296 patients), OR could be extracted from 11 studies including 905 patients (464 survivors vs. 441 non-survivors), and 17 studies reported EVLW values of survivors and non-survivors, including 1246 patients (680 survivors vs. 566 non-survivors). The pooled OR of EVLW for mortality from eleven studies was 1.69 (95% confidence interval (CI) [1.22; 2.34], p < 0.0015). EVLW was significantly lower in survivors than non-survivors, with a mean difference of -4.97 mL/kg (95% CI [-6.54; -3.41], p < 0.001). The results regarding OR and mean differences were consistent in subgroup analyses. CONCLUSIONS: The value of EVLW measured by TPTD is associated with mortality in critically ill patients and is significantly higher in non-survivors than in survivors. This finding may also be interpreted as an indirect confirmation of the reliability of TPTD for estimating EVLW at the bedside. Nevertheless, our results should be considered cautiously due to the high risk of bias of many studies included in the meta-analysis and the low rating of certainty of evidence. Trial registration the study protocol was prospectively registered on PROSPERO: CRD42019126985.

B-Lines for the assessment of extravascular lung water: Just focused or semi-quantitative?

BACKGROUND: B-lines as typical artefacts of lung ultrasound are considered as surrogate measurement for extravascular lung water. However, B-lines develop in the sub-pleural space and do not allow assessment of the whole lung. Here, we present data from the first observational multi-centre study focusing on the correlation between a B-lines score and extravascular lung water in critically ill patients suffering from a variety of diseases. PATIENTS AND METHODS: In 184 adult patients, 443 measurements were obtained. B-lines were counted and expressed in a score which was compared to extravascular lung water, measured by single-indicator transpulmonary thermodilution. Appropriate correlation coefficients were calculated and receiver operating characteristics (ROC-) curves were plotted. RESULTS: Overall, B-lines score was correlated with body weight-indexed extravascular lung water characterized by r = .59. The subgroup analysis revealed a correlation coefficient in patients without an infection of r = .44, in those with a pulmonary infection of r = .75 and in those with an abdominal infection of r = .23, respectively. Using ROC-analysis the sensitivity and specificity of B-lines for detecting an increased extravascular lung water (>10 mL/kg) was 63% and 79%, respectively. In patients with a P/F ratio <200 mm Hg, sensitivity and specificity to predict an increased extravascular lung water was 71% and 93%, respectively. CONCLUSIONS: Assessment of B-lines does not accurately reflect actual extravascular lung water. In presence of an impaired oxygenation, B-lines may reliably indicate increased extravascular lung water as cause of the oxygenation disorders.

[Uncertain Acute Hemodynamic Instability after Severe Burn Injury: an (Un-)Usual Complication]. / Unklare akute Kreislaufinstabilität nach Stromunfall: eine (un-)gewöhnliche Komplikation.

First aid and treatment of burn patients pose a challenge to responsible physicians. Primary assessment should include an evaluation of the degree and extent of the burn injuries as well as a physical examination for other trauma injuries and trauma caused by the inhalation of toxic agents. One should focus on removal of the burning source, preservation of body temperature, sterile coverage of the burnt areas, pain management and sufficient hemodynamic stabilization. Grade IIb and more severe burns are most likely subject to surgical intervention to assure sufficient healing. Our case report illustrates a burn patient's initial treatment and clinical course, which includes the development of an acute pulmonary embolism with severe hemodynamic instability. As other critically ill patients, burn patients are at particular risk for complications like infections or other causes for hemodynamic instability. Every cardiovascular event is possibly suspicious for acute pulmonary arterial embolism (PAE). A high or increasing gap between expiratory and arterial CO2 tension accompanied by typical symptoms like tachycardia and hypotension or respiratory distress may be caused by PAE. An echocardiogram can provide information about possible pathophysiological changes typical for PAE, nevertheless, CT-angiography is today's clinical gold standard for the diagnosis of PAE. As therapeutic measures, heparin should be administered, and thrombolysis should be considered in case of persisting hemodynamic instability, attentively taking possible contraindications into account.

[Role of Procalcitonin as a Sepsis Marker]. / Stellenwert des Procalcitonins als Sepsismarker.

Adequate diagnosis and therapy of sepsis is of major prognostic relevance. Besides the gold standard (blood culture diagnostics) biomarkers, e.g. serum procalcitonin (PCT), are clinically increasingly used in the diagnosis and for guiding anti-infective treatment. Recent guidelines recommend early determination of PCT. However, trauma, burns, surgical procedure, and intoxications may significantly impact PCT levels. As a rare cause, PCT producing tumors have been described and may be potentially misleading in the clinical setting. While several other constellations for increased PCT in the absence of sepsis (e.g., trauma, intoxications) have been described, it needs to be summarized that according to currently available data, sensitivity and specificity for PCT for the diagnosis of sepsis in critically ill patients is on average between 70 and 80%. Thus, PCT must be interpreted carefully in the context of medical history, physical examination, and microbiological assessment. However, the existing body of literature emphasizes the value of PCT to shorten the duration of an antibiotic treatment. So far, different cut-off values for PCT for certain infections have been identified. While different treatment algorithms have been studied, PCT-guided treatment not only enables to reduce use of antibiotics but as shown most recently may improve outcome of critically ill patients.

Assessment of liver perfusion and function by indocyanine green in the perioperative setting and in critically ill patients.

Indocyanine green (ICG) is a water-soluble dye that is bound to plasma proteins when administered intravenously and nearly completely eliminated from the blood by the liver. ICG elimination depends on hepatic blood flow, hepatocellular function and biliary excretion. ICG elimination is considered as a useful dynamic test describing liver function and perfusion in the perioperative setting, i.e., in liver surgery and transplantation, as well as in critically ill patients. ICG plasma disappearance rate (ICG-PDR) which can be measured today by transcutaneous systems at the bedside is a valuable method for dynamic assessment of liver function and perfusion, and is regarded as a valuable prognostic tool in predicting survival of critically ill patients, presenting with sepsis, ARDS or acute liver failure.

Validation of radial artery-based uncalibrated pulse contour method (PulsioFlex) in critically ill patients: A observational study.

BACKGROUND: Because of their simplicity, uncalibrated pulse contour (UPC) methods have been introduced into clinical practice in critical care but are often validated with a femoral arterial waveform. OBJECTIVE: We aimed to test the accuracy of cardiac index (CI) measurements and trending ability from a radial artery with one UPC. DESIGN: An observational study. SETTING: Tertiary care mixed-surgical ICU. Data were obtained from April 2015 to July 2016. PATIENTS: We studied 20 critically ill mechanically ventilated patients monitored by UPC (PulsioFlex; Pulsion Medical Systems SE, Feldkirchen, Germany). We used transpulmonary thermodilution (PiCCO2) as a reference. MAIN OUTCOME MEASURES: Bland-Altman-analyses with percentage errors were calculated to assess the accuracy of CI values from radial pulse contour analysis (CIRAD), autocalibration (CIAC) and femoral pulse contour analysis (CIFEM). All were compared with a reference (CITD) at 4-h intervals for 24 h. Trending ability was assessed by polar-plots and four-quadrant-plots. CI is given in l min m. RESULTS: Bland-Altman-analyses: for CIRAD, the mean bias was -0.1 with limits of agreement (LOA) of -2.9 to 2.7 and a percentage error of 70%; for CIAC, the mean bias was 0 with LOA -2.8 to 2.7 and a percentage error of 70%; for CIFEM, the mean bias was 0 with LOA -1.2 to 1.2 and a percentage error of 30%, respectively. Polar plots for trending: for CIRAD, the angular bias was 12° with radial LOA of 39°, a polar concordance rate of 73% and a concordance rate of 67% in the four-quadrant-plot; for CIAC, the angular bias was 4° with radial LOA of 41°, polar concordance rate of 79% and a concordance rate of 74% in the four quadrant plot; for CIFEM, the angular bias was -2° with radial LOA of 50°, polar concordance rate of 74% and a concordance rate of 81%. CONCLUSION: In critically ill patients, the PulsioFlex system connected to a radial arterial catheter is inaccurate for CI measurements and does not track changes in CI adequately. We therefore recommend using validated thermodilution techniques for monitoring in the critical care setting.

[The patient with intra-abdominal hypertension]. / Der Patient mit intraabdomineller Hypertension - Was gilt es beim anästhesiologischen Management zu beachten?

An intra-abdominal hypertension (IAH) defined as a pathological increase in intra-abdominal pressure (IAP) is commonly found on ICU admission or during the ICU stay. Several studies confirmed that an IAH is an independent predictor for mortality of critically ill patients. The abdominal compartment syndrome (ACS) which is defined as a sustained IAP>20 mmHg (with or without an abdominal perfusion pressure [APP]<60mmHg) that is associated with new organ dysfunction or failure has a mortality of up to 60%. In general, an IAH may be induced by several intra-abdominal as well as extra-abdominal conditions. Reduced abdominal wall compliance, intra-abdominal pathologies (either of the peritoneal space or parenchymateous organs) may lead to an IAH. Most commonly, intra-abdominal infections and/or sepsis and severe trauma or burns are predisposing for an IAH. An early sign may be a decrease in urinary output. The effects of an increased IAP on cardiovascular function are well recognized and include negative effects on preload, afterload and contractility. However, all other compartments of the body may be affected by an IAH. Thus, by an increase of the respective compartment pressure, e.g. intracranial pressure, a poly-compartment syndrome may result. Adequate prevention, a forward-looking strategy, and objective techniques for measurement of IAP are required to avoid or early detect an IAH or ACS. Finally, an immediate and consequent interdisciplinary management using conservative, interventional and operative options are necessary to solve an IAH or ACS.

[Drug interactions in intensive care medicine]. / Medikamenteninteraktionen--In der Intensivmedizin.

Drug-drug interactions are a common problem in elderly multi-morbid patients receiving polypharmacy. A high quantity of prescribed drugs is associated with an increase in the risk of adverse effects and drug-drug interactions. More and more medical and pharmaceutical stakeholders are involved in the drug therapy of critically ill patients. In the future it will be important to comprehend the medication as a common task. The patient will get the best therapy available, if the cooperation is successful. In general, drug interactions may be related to pharmacokinetic and pharmacodynamic aspects. Pharmacokinetic drug interactions concern the influence of the cytochrome P450 enzymes and transport proteins in the body. Pharmacodynamic interactions can be found, for example, as an additive effect of drugs which are combined. The relevance of both aspects must accordingly be considered and negative impact should be avoided.

Perioperative goal-directed hemodynamic therapy based on radial arterial pulse pressure variation and continuous cardiac index trending reduces postoperative complications after major abdominal surgery: a multi-center, prospective, randomized study.

INTRODUCTION: Several single-center studies and meta-analyses have shown that perioperative goal-directed therapy may significantly improve outcomes in general surgical patients. We hypothesized that using a treatment algorithm based on pulse pressure variation, cardiac index trending by radial artery pulse contour analysis, and mean arterial pressure in a study group (SG), would result in reduced complications, reduced length of hospital stay and quicker return of bowel movement postoperatively in abdominal surgical patients, when compared to a control group (CG). METHODS: 160 patients undergoing elective major abdominal surgery were randomized to the SG (79 patients) or to the CG (81 patients). In the SG hemodynamic therapy was guided by pulse pressure variation, cardiac index trending and mean arterial pressure. In the CG hemodynamic therapy was performed at the discretion of the treating anesthesiologist. Outcome data were recorded up to 28 days postoperatively. RESULTS: The total number of complications was significantly lower in the SG (72 vs. 52 complications, p = 0.038). In particular, infection complications were significantly reduced (SG: 13 vs. CG: 26 complications, p = 0.023). There were no significant differences between the two groups for return of bowel movement (SG: 3 vs. CG: 2 days postoperatively, p = 0.316), duration of post anesthesia care unit stay (SG: 180 vs. CG: 180 minutes, p = 0.516) or length of hospital stay (SG: 11 vs. CG: 10 days, p = 0.929). CONCLUSIONS: This multi-center study demonstrates that hemodynamic goal-directed therapy using pulse pressure variation, cardiac index trending and mean arterial pressure as the key parameters leads to a decrease in postoperative complications in patients undergoing major abdominal surgery. TRIAL REGISTRATION: ClinicalTrial.gov, NCT01401283.

The influence of prone positioning on the accuracy of calibrated and uncalibrated pulse contour-derived cardiac index measurements.

BACKGROUND: Patients with lung failure who undergo prone positioning often receive extended hemodynamic monitoring. We investigated the influence of modified prone positioning (135°) on the accuracy of pulse contour-derived calibrated cardiac index (CIPC) and uncalibrated cardiac index (CIVIG) in this patient population with transpulmonary thermodilution (TPTD) as reference technique. METHODS: We studied 16 critically ill and mechanically ventilated patients (11 men, 5 women, aged 20-71 years) with acute lung injury or acute respiratory distress syndrome. Patients were monitored by TPTD with an integrated calibrated pulse contour technique (PiCCO®) and by uncalibrated pulse contour analysis (FloTrac/Vigileo™). Before prone positioning, cardiac index (given in L·min(-1)·m(-2)) was measured by TPTD (CITPTD) and CIPC was calibrated. After positioning, CIPC and CIVIG were read from the monitor and CITPTD was measured. After 8 to 10 hours, prone positioning was completed and measurements were performed analogously. Bland-Altman analysis based on a random-effects model was used to calculate limits of agreement (LOA) and percentage errors. Polar plots were used for trend analysis. RESULTS: Supine CITPTD was 3.3 ± 0.9 (mean ± SD) and CIVIG was 3.1 ± 0.8. After proning, CIPC was 3.5 ± 0.8, CIVIG 3.3 ± 0.8, and CITPTD 3.6 ± 0.8. Before repositioning, CITPTD was 3.5 ± 0.7 and CIVIG 3.3 ± 1.0. After repositioning, CITPTD was 3.1 ± 0.7, CIPC 3.3 ± 0.7, and CIVIG 2.9 ± 0.6. Mean bias pooled for proning and repositioning was -0.1 (LOA -0.7 to 0.6) for CIPC (percentage error 19%) and 0.3 (LOA -1.3 to 1.9) for CIVIG (percentage error 48%). Changes in CI were too small for trending analysis. CONCLUSION: Although calibrated CI measurements are only marginally influenced by prone positioning, according to the criteria of Critchley and Critchley, uncalibrated CI values show a degree of error, too high to be considered clinically acceptable.

Erroneous continuous cardiac output by calibrated pulse contour analysis.

Pulse contour analysis techniques are used for beat-to-beat tracking of cardiac output in critically ill patients. However, an adequate pulse pressure waveform signal and identification of the appropriate (i.e. systolic) part of the waveform by the monitor are crucial for correct calculation of continuous cardiac output. We observed a case where the monitor failed to correctly identify the systolic part of the waveform during tachycardia thus giving false readings. We would like to emphasize the importance of visually checking the waveform for any irregularities that may cause erroneous calculations before initiating a therapy based on these values. One advantage of the system used here is that the part of the pressure curve used for analysis is automatically indicated.

[Air embolism after removal of central venous catheter]. / Kasuistik - Luftembolie nach ZVK-Entfernung.

Placement and removal of central venous catheters (CVC) are routine procedures in anesthesiology and on the intensive care unit. There are numerous possible complications associated with those interventions. Here, we report on a patient who developed respiratory failure immediately after removal of a CVC. The proof of air bubbles in echocardiography confirmed the diagnosis of air embolism. In this article we describe causes, symptoms and therapy of air embolism.

[Case report. Leukocytosis in the course of Clostridium difficile infection]. / Kasuistik. Leukozytose im Zuge einer Clostridium-difficile-Infektion.

Clostridium difficile infections (CDI) are increasing in incidence and severity, amongst other reasons because of the increasing spread of hypervirulent strains. Leukocytosis is a sign of severe CDI and is predictive for a complicated course. In this case report, we describe 2 patients with CDI who developed leukocytosis within a leukemoid range. In both cases high white blood cell counts returned totally to normal range under CDI therapy according to guidelines. Leukemia-related therapy patterns were not needed. Notably, in none of the patients a hypervirulent strain was isolated.

The transpulmonary thermodilution technique.

The transpulmonary thermodilution technique (TPTD) is a safe, multi-parametric advanced cardiopulmonary monitoring technique that provides important parameters required for making decisions in critically ill patients. The TPTD provides more reliable indicators of preload than filling pressures, the unique measurement of extravascular lung water (EVLW) and comparable accuracy in measuring cardiac output (CO). Intermittent measurement of the CO by TPTD when coupled with pulse contour analysis, offer automatic calibration of continuous CO, as well as accurate assessment of volumetric preload, fluid responsiveness and EVLW. TPTD-guided algorithms have been shown to improve the management of high-risk surgical and critically ill patients.

Potential impact of cell-free DNA blood testing in the diagnosis of sepsis.

BACKGROUND: Classical blood culture testing is still the gold standard in correct and timely diagnosis of the responsible microorganisms in sepsis. CASE SUMMARY: In this case (a patient with a colon perforation and severe peritonitis with septic shock), an alternative approach (cell-free DNA next-generation sequencing from full blood samples, NGS) showed the responsible microorganisms, whereas the classical blood culture testing remainedstayed sterile. Interestingly, samples from the abdominal fluid showed the same bacteria as NGS. CONCLUSION: These findings may be interpreted as that the threshold for positive testing is lower through the molecular approach than through culture techniques; however, more studies are necessary to prove this theory.

Epidemiology and risk factors of sepsis after multiple trauma: an analysis of 29,829 patients from the Trauma Registry of the German Society for Trauma Surgery.

OBJECTIVES: The objectives of this study were 1) to assess potential changes in the incidence and outcome of sepsis after multiple trauma in Germany between 1993 and 2008 and 2) to evaluate independent risk factors for posttraumatic sepsis. DESIGN: Retrospective analysis of a nationwide, population-based prospective database, the Trauma Registry of the German Society for Trauma Surgery. SETTING: A total of 166 voluntarily participating trauma centers (levels I-III). PATIENTS: Patients registered in the Trauma Registry of the German Society for Trauma Surgery between 1993 and 2008 with complete data sets who presented with a relevant trauma load (Injury Severity Score of ≥ 9) and were admitted to an intensive care unit (n = 29,829). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Over the 16-yr study period, 10.2% (3,042 of 29,829) of multiply injured patients developed sepsis during their hospital course. Annual data were summarized into four subperiods: 1993-1996, 1997-2000, 2001-2004, and 2005-2008. The incidences of sepsis for the four subperiods were 14.8%, 12.5%, 9.4%, and 9.7% (p < .0001), respectively. In-hospital mortality for all trauma patients decreased for the respective subperiods (16.9%, 16.0%, 13.7%, and 11.9%; p < .0001). For the subgroup of patients with sepsis, the mortality rates were 16.2%, 21.5%, 22.0%, and 18.2% (p = .054), respectively. The following independent risk factors for posttraumatic sepsis were calculated from a multivariate logistic regression analysis: male gender, age, preexisting medical condition, Glasgow Coma Scale score of ≤ 8 at scene, Injury Severity Score, Abbreviated Injury ScaleTHORAX score of ≥ 3, number of injuries, number of red blood cell units transfused, number of operative procedures, and laparotomy. CONCLUSIONS: The incidence of sepsis decreased significantly over the study period; however, in this decade the incidence remained unchanged. Although overall mortality from multiple trauma has declined significantly since 1993, there has been no significant decrease of mortality in the subgroup of septic trauma patients. Thus, sepsis has remained a challenging complication after trauma during the past 2 decades. Recognition of the identified risk factors may guide early diagnostic workup and help to reduce septic complications after multiple trauma.

[Intra-arterial ECG leads of a positive P-wave potential during central venous catheterization]. / Kasuistik: Fehlerhafte Lage eines zentralen Venenkatheters trotz korrekter intravasaler EKG-Ableitung. Positives P-Wellenpotenzial bei intraarterieller Katheterfehllage.

The application of a central venous catheter (CVC) is a routine procedure in anaesthesia and intensive care medicine. Although the procedure is generally carried out without complications, nevertheless numerous and, in part acute life threatening and lethal complications have been described. The complication rate during placement of a CVC is up to 12%. To ensure the correct position of the catheter, different methods may be used: for example the intravascular feeder of a positive P-wave of the ECG. In the case of a position check via the ECG (α-Card), the catheter's point serves as a unipolar electrode. The intraatrial ECG lead is used as a raised and heightened P-wave potential for the correct catheter position. In this case, we present a 65 year-old critically ill patient with an occlusion of the right superficial femoral artery and acute respiratory distress syndrome (ARDS) in whom a puncture trial of the right internal jugular vein was carried out. This was followed by the placement of the CVC intended for the right internal jugular vein which, however, turned out to be a direct puncture of the right carotid artery. Despite the inaccurate intra-arterial position, forwarding of the catheter showed a typical raised and heightened P-wave potential. The artery puncture was checked via a blood gas analysis and the artery blood pressure diagram tracing. The removal and correct placement of the CVC were achieved without any problems. These findings emphasize the P-wave potential in the ECG feeder does not correlate with the transition from the superior vena cava to the right atrium. Consequently, this does not preclude an intra-arterial malposition.