[Vomiting and collapse of a 28-year-old male long distance runner in middle European Summer]. / Erbrechen und Kollaps bei einem 28-jährigen Langstreckenläufer im mitteleuropäischen Sommer.

BACKGROUND: Hyperthermia often ends fatally and must therefore be promptly recognized and adequately treated. CASE: A 28-year-old man participated in a long-distance race (3 km) on a hot summer day (28 °C). The runner collapsed, had to vomit but continued the run and reached the finish. Neurologically, the patient presented with intermittent cerebral seizures. External cooling batteries were immediately applied and cold infusions were started. The patient was admitted to the intensive care unit of the university hospital (body temperature 40.2 °C). After a few hours, a manifest disseminated intravascular coagulopathy developed with multiple organ failure. It took 12 l of volume replacement, 8 units of fresh frozen plasma and 2 units of erythrocyte concentrates in the first 12 h to stabilize the patient. Although with the help of forced external cooling and application of cold infusions, the body temperature could be lowered to 38 °C by the next morning, the overall situation of the patient continued to deteriorate. Despite dialysis and massive substitution of coagulation factors, the patient could not be sufficiently stabilized and died of brain edema. CONCLUSION: Not only the old or young children are subject to the potential danger of a fatal heat stroke but also young athletic persons after normal sports activities (3 km run). Cooling must be started immediately and the patient must be hospitalized as a vital emergency. If hemostasis fails due to the heat-related loss of hepatogenic protein synthesis, a viscious circle begins, which, as in the reported case, is irreversible despite maximum therapy and substitution.

[Antibiotic Consumption and the Development of Antibiotic Resistance in Surgical Units]. / Antibiotikaverbrauch und Resistenzentwicklung in der Chirurgie.

BACKGROUND: Antibiotic resistence is increasing worldwide. AIM: A longitudinal analysis of the influence of the density of antibiotic use on the development of resistance in surgical units was undertaken. MATERIAL AND METHODS: Over five years the incidence of pathogens and the resistance rates of isolates from patients of normal surgical units and those of a surgical ICU at a university hospital were examined. The resistence rates were correlated with the density of antibiotic use - calculated from the antibiotic consumption (in DDD) and the number of patient-days. RESULTS: At both units, Enterobacteriaceae and Enterococci were mostly cultured. Among the Enterobacteriaceae, E. coli, Klebsiella spp., Proteus mirabilis and Enterobacter predominated. In the group of Enterococci, E. faecalis predominated at wards whereas at ICU E. faecium was the most frequent. Anaerobes ranked third at normal wards and Candida spp. at ICU. From 2007 to 2011, there was an increasing resistance against ciprofloxacin in P. mirabilis (r = 0.87; p = 0.054) and against imipenem (r = 0.86; p = 0.06) and piperacillin (r = 0.81; p = 0.09) in P. aeruginosa at normal wards. At ICU, the resistance rates of imipenem in P. aeruginosa rose (r = 0.88; p = 0.049). Resistance against ciprofloxacin in E. coli increased (r = 0.65; p = 0.23). Due to the increasing use of ciprofloxacin and meropenem at normal wards, the density of antibiotic usage rose 1.4 %/year (r = 0.94; p = 0.02). Despite the increase of meropenem use at ICU (r = 0.9; p = 0.035), the total antibiotic uptake rate remained almost constant. The antibiotic usage density was 3-fold higher at ICU than at normal wards. At normal wards, the ciprofloxacin usage correlated with the rate of resistance against ciprofloxacin in P. mirabilis P. m. At ICU, an association was detected between the uptake rate of ceftazidime and the rate of resistance against cefotaxime in the CES group. In P. aeruginosa, the use of piperacillin and the rate of resistance against piperacillin correlated. CONCLUSION: The high uptake rates of fluoroquinolones and carbapenems were accompanied by increases in resistances. The resistance rates are influenced by hygiene management and microbiological diagnostics. The extensive use of carbapenems should be reassessed on both units to counter further development of antibiotic resistance.

[Successful closure of a postoperative esophagobronchial fistula following esophageal resection using fibrin glue]. / Erfolgreicher Fibrinkleber-basierter Verschluss einer postoperativen ösophagobronchialen Fistel nach Ösophagusresektion.

UNLABELLED: HISTORY AND INTERVENTION: A 52-year-old female patient underwent open abdominothoracic cardia and esophageal resection with gastric transposition because of histologically diagnosed Barrett metaplasia with "high-grade" intraepithelial neoplasia (HGIEN) and parts of an invasive adenocarcinoma. The anastomotic insufficiency on the 10th postoperative day including an esophagobronchial fistula prompted to a subsequent surgical re-intervention with suture of the fistula, lavage and additional drainage, an endoscopic stenting of the fistula from esophageal site, as well as repeated (n = 22) bronchoscopic applications of fibrin glue (1-3 ml each) into the lumen of the fistula after each bronchoscopic lavage of the fistula until the complete closure was achieved. The changeful clinical course of 77 days on the surgical ICU was characterized by secondary complications such as pneumonia, mediastinitis and respiratory insufficiency with long-term artificial respiration and creation of a percutaneous dilatation tracheotomy. CONCLUSION: The application of fibrin glue can be considered a promising, minimally invasive therapeutic option in the management of postoperative fistula after esophageal resection, which requires expertise in decision-making and the finding-specific approach, in particular, if indicated inital steps of the sequential complication management such as surgical re-intervention and conventional endoscopic measures (stenting, Endo-VAC[-sponge]) do not provide great therapeutic potential any more due to the prolonged postoperative time course and the unfavorable local findings. In the presented case, modes of an assisted artificial respiration with low pressure and short phases of apnoe after fibrin glue application were the crucial predictions for an initial and favorable adhesion of this glue and finally for a successful sealing resulting in a sufficient closure of the fistula.

[Molecular biological sepsis diagnostic using multiplex PCR in surgical intensive care as suitable alternative to conventional microbial culture - a representative overview]. / Molekularbiologische Sepsisdiagnostik mittels Multiplex-PCR in der chirurgischen Intensivmedizin als geeignete Alternative zur konventionell-mikrobiellen Kultur - ein repräsentativer Überblick.

INTRODUCTION: Sepsis causes a substantial rate of morbidity and mortality in intensive care patients, which is, in particular, triggered by an inadequate antimicrobial treatment from the beginning. Conventional microbiological standard procedures cannot provide valuable information on bacterial or fungal species of sepsis-relevant microbes within the first hours of a developing sepsis. However, multiplex PCR (PCR-M) focussing on the spectrum of the most relevant sepsis-associated microbes can considerably shorten the time period; the analytical tests have been standardised and, subsequently, inaugurated into clinical practice; they also have thus been available since 2005. Interestingly, in the surgical field an appropriate summary and concluding recommendation have been lacking so far. AIM, MATERIAL AND METHODS: A compact short overview based on a characteristic selection of relevant references from the literature is given on the commercially available sepsis-associated multiplex-PCR methods, reflecting critically the time point of inauguration, clinical value and future perspectives including our own experiences from clinical practice and medical studies. RESULTS: Multiplex PCR in adult sepsis patients yielded in a range from 13.7 to 39.9 % of positive findings, whereas conventional blood cultures only range from 8 to 29.9 %. From 8 to 16.9 % of all investigations performed prompted us to a change of the antimicrobial treatment by using a positive PCR-M finding. A prospective study (end-point, reduction of sepsis-associated mortality) has not yet been initiated. Positive PCR-M findings correlate with an increased morbidity and mortality as well as clinical and laboratory sepsis parameters. Recent studies have aimed for a comparison of PCR-M on sepsis-associated microbes with regard to specificity and sensitivity with the current "gold standard", conventional blood culture. A few studies wrongly claimed to compare the methods because of the difference in the procedures; in addition, blood culture as gold standard has been increasingly considered as very problematic from a methodological point of view. Recent publications on multiplex-PCR studies in frequently heterogenic groups of patients have been mostly performed with the Lightcycler-Septifast® test (LC-SF) with great success. The procedure has provided evidence of an improved detection rate of sepsis-associated microbes, favourable concordance of positive PCR-M findings with clinical and laboratory sepsis parameters and substantial time-saving in the microbiological analysis of the specific microbial species, which is simultaneously associated with an earlier initiation of an adequate antimicrobial treatment regimen. CONCLUSION: The available study data suggest that systrematic investigations on the molecular biological procedures should be rather related to a different standard based on the LC-SF. Positive PCR-M findings have been accepted as a sepsis marker in the mean time.

[Spectrum of microbial colonisation and resistance of a surgical ICU in a systematic comparison of the 10-year time period 1996-2005 using routine microbiological testing]. / Erreger- und Resistenzspektrum einer chirurgischen ITS im systematischen 10-Jahres-Vergleich 1996-2005 im Rahmen des mikrobiologischen Routinemonitorings.

INTRODUCTION: Knowledge on potentially pathogenic microbes including characteristics of their antibiotic resistance in septic patients as well as on the ward- and department-specific microbial spectrum can be considered essential for an efficient initiation of an adequate antimicrobial treatment, which turns out to become pivotal for patient outcome. Permanent changes in microbial patterns and antibiotic resistance can only be identified by a continuous investigation of various microbiological specimens. AIM: Based on the retrospective evaluation of prospectively collected data on microbiological investigations of the surgical ICU in 1996, 2002, 2004 and 2005, the short- and long-term changes by trend of microbial spectrum and antibiotic resistance following reorganisation and restructuring of the University Hospital from the more traditional pavillon-based system to a multidisciplinary complex building in 2003 were investigated. MATERIAL AND METHODS: Twice a week, routine microbiological testing of blood and urinary cultures as well as swabs from wound areas and endotracheal swabs were initiated in septic patients (suspect, manifestation) or in case of their clinical impairment. The microbial spectrum was sub-divided according to Gram-staining (Gram-positive/ -negative), various species and fungi with descriptive absolute and relative data values. -Various groups and time periods were statistically compared using χ² test as appropriate. P values < 0.05 were considered statistically significant. RESULTS: In total (n (Total) = 4 899), microbiological testing resulted in the detection of microbes in 699 and 833 blood and urinary cultures (14.3 % and 17 %, respectively) as well as 1 232 wound swabs (25.1 %) together with 2 135 samples from the endotracheal sites (43.6 %). During the short- (2002 vs. 2004) and long-term analyses (1996 vs. 2005), the proportion of Gram-positive microbes increased. Al-though Gram-positive bacteria can be considered the most frequent microbes for bacteriemia, there was a shift onto urinary and wound infections as well as pneumonias through the observation period. Despite the decreasing incidence of Enterococcus and the consistent proportion of MRSA, the increase of resistant Enterococcus strains (0 % vs. 43.2 %; P < 0.05) is critical. However, in the Gram-negative microbial spectrum there was an increase of the bacteraemia rate but a fall of the detection rate in wound and endotracheal swabs. In parallel, an increase of the detection rate of E. coli in blood (6.5 % vs. 45.5 %; P < 0.05) and endotracheal swabs (9.2 % vs. 16.2 %; P < 0.05) is associated with an increase of multiresistant Enterobacteriaceae strains (0 % vs. 30.7 %; P < 0.05). The portion of multiresistant strains of Pseudomonas with 31 % stayed the same through the 10-year time period. While Candida-based colonisation showed a decreased incidence (25 % vs. 15 %; P < 0.05) during the whole investigation period, there was a relative rise in the frequency of candidemia. CONCLUSION: ICU relocation from the pavillon-based system to a new complex clinic building was not associated with any significant alteration of the microbial spectrum on the surgical ICU. Increasing incidences of resistant Enterococcus and Gram-negative problematic microbes may indicate a general spread of multi-resistant microbes under the steady selecting pressure of a not always adequately initiated antibiotic / antimicrobial therapeutic regimen and underline the required but specific and selected microbiological screening.

[Microbiological sepsis screening in surgical ICU patients with the "lightCycler" Septifast test--a pilot study]. / Mikrobiologisches Sepsis-Screening chirurgischer Intensivpatienten mit dem "Lightcycler" Septifast-Test--eine Pilotstudie.

INTRODUCTION: An adequate approach to surgically induced sepsis needs an early and targeted antibiotic therapy in addition to focus sanitation. The PCR-based LightCycler Septifast test can detect 90 % of the sepsis-associated microoganisms (e. g., Gram-positive, Gram-negative bacteria, fungi) within only a few hours. PATIENTS AND METHODS: A systematic microbiological screening was performed using conventional cultures from blood, urine, drain material and tracheal secretions as well as with the culture-independent Septifast test (blood supplemented with EDTA) as a comparison in consecutive surgical patients on the intensive care unit within a defined time period. RESULTS: Overall, 52 patients were enrolled in the investigation during the study period of 4 months. Out of overall 258 Septifast tests, 33 (12.8 %) were positive. Additional information on the microbial spectrum was achieved in 24 cases (72.2 %) when compared with the simultaneously performed conventional blood cultures; 32 (12.4 %) of 258 blood cultures were positive. If the frequent occurrence of coagulase-negative STAPHYLOCOCCUS (CNS) is classified as contamination, blood cultures resulted 10 times (31.3 %) in additional information compared with the Septifast test including the CNS in 20 cases (62.5 %). Except for Proteus mirabilis, this refers to microorganisms which are not in the analytical spectrum of the Septifast(R) test. A positive Septifast test showed a high coincidence with SIRS (75.8 %). CONCLUSION: This first systematic use of the time-saving LightCycler Septifast test shows that it can detect bacteremia in surgical patients at the ICU, with, in part, negative blood cultures. Positive Septifast test results which cannot be explained by clinical symptoms, occur rarely. The detection of pathological microbes with the Septifast test provides additional findings (72.2 %) for therapeutic decision-making, which can be obtained considerably more rapidly in comparison with conventional microbiological cultures (a few hours versus 2 days). For surgical patients with SIRS and subsequent need of intensive care, a Septifast test should be considered. In conclusion, it is recommended that the test should be further and systematically investigated.

[Total intravenous anesthesia (TIVA) and balanced anesthesia with short-acting anesthetics for ENT surgery in children]. / Totale intravenöse Anästhesie (TIVA) und balancierte Anästhesie mit kurzwirkenden Anästhetika für HNO-Eingriffe bei Kindern.

It was the aim of this study to compare total intravenous anaesthesia (TIVA) with balanced anaesthesia using modern short-acting anaesthetics for ENT-surgery in children regarding the influence on haemodynamics, recovery, side-effects and costs. After approval of the Ethics Committee of the Medical Faculty of the University of Rostock, 80 children in the age of 3 to 12 years, rectally premedicated with midazolam (0.3 mg/kg) and atropine (0.01 mg/kg), were randomly assigned to TIVA (group 1, n = 41) and balanced anaesthesia (group 2, n = 39), respectively. TIVA was induced with propofol (2 mg/kg) and remifentanil (1 microgram/kg) and maintained with propofol (6 mg/kg/h) and remifentanil (0.2 microgram/kg/min). Controlled ventilation was performed with an air/oxygen mixture (1:1). Balanced anaesthesia was induced with the method of "single breath induction" using sevoflurane (8 Vol.%) in a mixture of nitrous oxide/oxygen (2:1). For maintaining balanced anaesthesia under low flow conditions, sevoflurane concentration was reduced to 1 Vol.% while the nitrous oxide/oxygen mixture was kept constant. Additionally 0.1 microgram/kg/min of remifentanil was given. For controlled ventilation, the patients of both groups were primarily relaxed for intubation with mivacurium (0.2 mg/kg) under continuous monitoring using TOF-stimulation (TOF-Guard). Further relaxation was performed with doses of 0.05 mg/kg of mivacurium after relaxometric control reached T1-level > 20% and T2-level > 0. Haemodynamic parameters (heart rate, mean arterial blood pressure), awakening time (time until the first spontaneous movements occurred), recovery time (according to Aldrete-Score > 8), side-effects (sevoflurane-induced excitation and propofol-induced pain due to the injection during induction of anaesthesia, postoperative vomiting) and costs for anaesthetic agents and relaxants were registered. The investigation showed significantly higher heart rate (p < 0.05) and significantly lower mean arterial pressure (p < 0.05) during balanced anaesthesia than during TIVA. Between the two groups there were no statistically significant differences regarding awakening time, recovery time and incidence of postoperative vomiting. In the TIVA-group, pain due to injection of propofol occurred in 10 patients (24.4%) and in group 2 sevoflurane-induced excitation during induction was registered in 22 patients (56.4%). Based on our presently existing purchase prices for the drugs used, there were no significant differences between the costs for TIVA and balanced anaesthesia. We conclude that both TIVA and balanced anaesthesia performed with short-acting anaesthetics, are suitable anaesthetic methods for ENT operations in children. Because balanced anaesthesia with sevoflurane led to higher heart rates, this kind of anaesthesia should be used with caution in children with heart diseases. The main advantage of both methods is their short recovery time.