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When conducting clinical trials in intensive care and emergency medicine, physicians, ethics committees, and legal experts have differing views regarding the inclusion of patients who are incapable of giving consent. These different views on the participation of patients who are not capable of giving consent also complicate how clinical trials are prepared and conducted. Based on the results of a literature search, a consensus model (Cologne Model) was developed by physicians performing clinical research, ethics committees, and lawyers in order to provide patients, those scientifically responsible for the study, ethics committees, and probate (guardianship) judges with a maximum of patient safety and legal certainty, while simultaneously enabling scientific research.
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The management of hemodynamic instability in the context of sepsis or septic shock is at the forefront in emergency care as well as in the intensive care unit. Cardiovascular instability has a dramatic impact on the rate of organ complications and mortality from sepsis. According to the guideline for the treatment of sepsis, mean arterial pressure should not fall below 65â¯mmâ¯Hg. Crystalloid balanced fluid and catecholamines are the cornerstones of therapy management for septic cardiovascular instability. In this article, the most important points of what, when and how much regarding circulation therapy are presented and critically discussed.
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Catecolaminas/uso terapéutico , Soluciones Cristaloides/uso terapéutico , Sepsis/tratamiento farmacológico , Fluidoterapia , Humanos , Unidades de Cuidados Intensivos , Sepsis/diagnóstico , Choque SépticoRESUMEN
INTRODUCTION: Cancer is one of the leading causes of death worldwide. Due to increasing comorbidities, age and aggressive chemotherapy, care of cancer patients in intensive care units (ICUs) is more and more necessary. So far, little is known about the care structure of cancer patients in German ICUs. The aim of this work is to collect and evaluate the prevalence and care data of cancer patients on two reference dates. METHODS: German ICUs were invited to participate in a 2-day, prospective, multicenter point prevalence study in ICU cancer patients. Participation in the study was voluntary and the study was not funded. An ethics vote was obtained to conduct the study. The data were anonymously entered into an eCRF (electronic case report form) by the participating centers. Identification of the patients is therefore not possible. RESULTS: About one in four patients on the ICU/IMC ward had hematological-oncological (HO) disease (nâ¯= 316/1319, 24%). The proportion depended significantly on the number of beds in each hospital. The most frequent reasons for admission to the ICU/IMC station were postoperative monitoring (nâ¯= 83/221, 37.6%), respiratory instability (nâ¯= 79/221, 35.7%), circulatory instability (nâ¯= 52/221; 23.5%) and the severe infection with sepsis (nâ¯= 47/221; 21.3%). In all, 66.5% (nâ¯= 147/221) of the patients had a solid tumor and 21.7% (nâ¯= 48/221) had hematological cancer, 78.3% (nâ¯= 173/221) of the documented cancer patients received "full-code" intensive management, while 42.5% (nâ¯= 94/221) of the HO patients were ventilated and 40.7% (nâ¯= 90/221) required catecholamines. The median (mean; IQR) SAPS II score was 35 (37.79, IQRâ¯= 24-48) and the median (mean, IQR) TISS score was 10 (13.26, IQRâ¯= 10-15). Through the analysis and evaluation of the data available in the context of the prevalence study, it was possible for the first time to determine the Germany-wide cross-center prevalence and care situation of hematological cancer patients in intensive care and intermediate care stations. About one in four patients on German ICUs and IMC wards have a major or minor cancer diagnosis (nâ¯= 316/1319â¯= 24%). Care management is complex in this patient population and requires close interdisciplinary collaboration.
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Unidades de Cuidados Intensivos , Sepsis , Alemania , Humanos , Prevalencia , Estudios ProspectivosRESUMEN
BACKGROUND: The development of chimeric antigen receptor (CAR) Tcells has shown promising results in relapsed/refractory Bcell acute lymphoblastic leukemia/lymphoma (B-ALL) and diffuse large cell Bcell lymphoma. Complications, especially cytokine release syndrome (CRS) and CAR Tcell related encephalopathy syndrome (CRES), can be life threatening. The management of both plays a key role in CAR Tcell therapy. OBJECTIVES: Diagnosis, clinical presentation and development of complications in the treatment with CAR Tcells. MATERIALS AND METHODS: Summary of incidence, mortality and treatment of severe complications after administration of CAR Tcells referring to current studies and therapy recommendations. RESULTS: Complications after administration of CAR Tcells, especially CRS and CRES, can be life threatening. The timely identification of side effects and their appropriate treatment usually leads to complete recovery. CONCLUSIONS: Using a therapy algorithm in the treatment with CAR Tcells allows safe management of toxicities and can be helpful in recognizing them in time.
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Leucemia-Linfoma Linfoblástico de Células Precursoras/terapia , Receptores Quiméricos de Antígenos , Síndrome de Liberación de Citoquinas , Citocinas , Humanos , Inmunoterapia AdoptivaRESUMEN
BACKGROUND: Due to the use of checkpoint inhibitors, intensive care units will be confronted with an increasing number of patients with immune-related adverse events. A broad spectrum of symptoms and potentially lethal consequences make diagnosis and treatment challenging. OBJECTIVES: Diagnosis and treatment of immune-related adverse events in the treatment with checkpoint inhibitors with a special focus on intensive care units. MATERIALS AND METHODS: Review of current publications about incidence, symptoms and treatment of adverse events after the use of checkpoint inhibitors relevant for intensive care medicine. RESULTS: Immune-related adverse events during therapy with checkpoint inhibitors are difficult to diagnose and present with various symptoms. Severe complications can often successfully be treated with early therapy. CONCLUSIONS: The early treatment of immune-related adverse events according to their severity is needed to prevent a potentially life-threatening course.
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Cuidados Críticos , Humanos , IncidenciaRESUMEN
BACKGROUND: Severe pulmonary infections are among the most common reasons for admission to intensive care units (ICU). Within the last decade, increasing reports of severe influenza pneumonia resulting in acute respiratory distress syndrome (ARDS) complicated by Aspergillus infection were published. OBJECTIVES: To provide a comprehensive review of management of influenza-associated pulmonary aspergillosis in patients with ARDS. SOURCES: Review of the literature pertaining to severe influenza-associated pulmonary aspergillosis. PubMed database was searched for publications from the database inception to January 2019. CONTENT: In patients with lower respiratory symptoms, development of respiratory insufficiency should trigger rapid and thorough clinical evaluation, in particular in cases of suspected ARDS, including electrocardiography and echocardiography to exclude cardiac dysfunction, arrhythmias and ischaemia. Bronchoalveolar lavage should obtain lower respiratory tract samples for galactomannan assay, direct microscopy, culture, and bacterial, fungal and viral PCR. In case of positive Aspergillus testing, chest CT is the imaging modality of choice. If influenza pneumonia is diagnosed, neuraminidase inhibitors are the preferred approved drugs. When invasive aspergillosis is confirmed, first-line therapy consists of isavuconazole or voriconazole. Isavuconazole is an alternative in case of intolerance to voriconazole, drug-drug interactions, renal impairment, or if a spectrum of activity including the majority of Mucorales is desired. Primary anti-mould prophylaxis with posaconazole is recommended in haematology patients at high-risk. It may be considered in newly diagnosed influenza and ARDS, but ideally in clinical trials. IMPLICATIONS: The rising reports of influenza-associated pulmonary aspergillosis in patients with ARDS, who are otherwise not considered at risk for fungal pneumonia demands heightened clinical awareness. Tracheobronchitis and Aspergillus in respiratory tract samples should prompt suspicion of invasive fungal infection and further work-up. The management algorithm should comprise bronchoalveolar lavage, CT imaging, sophisticated ventilator-management, rescue extracorporeal membrane oxygenation, and antifungal and antiviral therapy. To decrease the burden of influenza-related illness, vaccination is of utmost importance, specifically in patients with co-morbidities.
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Cuidados Críticos , Gripe Humana/diagnóstico , Gripe Humana/terapia , Aspergilosis Pulmonar/diagnóstico , Aspergilosis Pulmonar/terapia , Algoritmos , Femenino , Humanos , Gripe Humana/complicaciones , Gripe Humana/patología , Unidades de Cuidados Intensivos , Persona de Mediana Edad , Aspergilosis Pulmonar/complicaciones , Aspergilosis Pulmonar/patología , Síndrome de Dificultad Respiratoria/complicaciones , Síndrome de Dificultad Respiratoria/diagnóstico , Síndrome de Dificultad Respiratoria/patología , Síndrome de Dificultad Respiratoria/terapia , Resultado del TratamientoRESUMEN
The number of treatment options and success of treating patients with cancer have both significantly increased in recent years. However, many of these patients require intensive care due to comorbidities, treatment-associated complications, or severe infections. At the same time, the boundaries between what is feasible and sensible are difficult to draw. Over the past few years, awareness of the problems these cancer patients may have in the intensive care unit has increased and discussions have begun. This article intends to offer a discussion basis and also possible solution strategies.
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Cuidados Críticos , Neoplasias , Cuidados Críticos/métodos , Cuidados Críticos/estadística & datos numéricos , Humanos , Unidades de Cuidados Intensivos/estadística & datos numéricos , Uso Excesivo de los Servicios de Salud , Neoplasias/complicaciones , Neoplasias/terapiaAsunto(s)
Síndrome Torácico Agudo/terapia , Anemia de Células Falciformes/terapia , Oxigenación por Membrana Extracorpórea/métodos , Síndrome Torácico Agudo/etiología , Anemia de Células Falciformes/sangre , Anemia de Células Falciformes/complicaciones , Anemia de Células Falciformes/tratamiento farmacológico , Anticoagulantes/administración & dosificación , Anticoagulantes/uso terapéutico , Terapia Combinada , Dobutamina/uso terapéutico , Hemorragia/prevención & control , Humanos , Hidroxiurea/uso terapéutico , Masculino , Insuficiencia Multiorgánica/etiología , Trombosis/prevención & control , Adulto JovenRESUMEN
Ethylene glycol poisoning of incidental or suicidal intention can cause life-threatening metabolic acidosis, diverse secondary damage, and even lead to death. Beside hemodialysis effective therapy consists of the administration of fomepizole and ethanol. We describe a patient after repeated ethylene glycol poisoning with high anion gap metabolic acidosis and acute renal failure. Using hemodialysis, with dialysate containing a specific amount of ethanol, and intravenous ethanol administration we were able to prevent severe secondary organ damage.
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Glicol de Etileno , Intoxicación , Adulto , Antídotos/uso terapéutico , Análisis Químico de la Sangre , Etanol/uso terapéutico , Glicol de Etileno/envenenamiento , Fomepizol/uso terapéutico , Humanos , Masculino , Intoxicación/terapia , Diálisis Renal , Intento de SuicidioRESUMEN
Raoultella planticola is a gram-negative, encapsulated, aerobic bacterium within the Enterobacteriaceae family. It has been primarily described as pathogen in cases with pneumonia and gastrointestinal infections. Here we describe a case of severe pelvic cellulitis in a patient with neutropenia following induction therapy for myeloid sarcoma. The patient experienced a septic shock and was treated successfully with antibiotic therapy. A literature review is provided to put this case in context with previous reports on R. planticola. This report highlights that awareness for uncommon pathogens is crucial in the clinical management of infections in neutropenic patients.
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Antibacterianos/uso terapéutico , Protocolos de Quimioterapia Combinada Antineoplásica/efectos adversos , Celulitis (Flemón)/microbiología , Neutropenia Febril Inducida por Quimioterapia/complicaciones , Infecciones por Enterobacteriaceae/microbiología , Enterobacteriaceae/aislamiento & purificación , Adulto , Celulitis (Flemón)/complicaciones , Celulitis (Flemón)/diagnóstico , Celulitis (Flemón)/tratamiento farmacológico , Neutropenia Febril Inducida por Quimioterapia/diagnóstico , Neutropenia Febril Inducida por Quimioterapia/etiología , Infecciones por Enterobacteriaceae/complicaciones , Infecciones por Enterobacteriaceae/diagnóstico , Infecciones por Enterobacteriaceae/tratamiento farmacológico , Humanos , Imagen por Resonancia Magnética , Masculino , Pelvis/diagnóstico por imagen , Sarcoma Mieloide/tratamiento farmacológico , Resultado del TratamientoAsunto(s)
Antivirales , Vacunas contra la Influenza/administración & dosificación , Gripe Humana/prevención & control , Antivirales/uso terapéutico , Alemania/epidemiología , Hospitalización/estadística & datos numéricos , Humanos , Gripe Humana/tratamiento farmacológico , Gripe Humana/epidemiología , Gripe Humana/virología , Estaciones del Año , Sociedades Médicas , VacunaciónRESUMEN
This consensus statement is directed to intensivists, hematologists, and oncologists caring for critically ill cancer patients and focuses on the management of these patients.
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Cuidados Críticos/normas , Neoplasias/terapia , Aloinjertos , Cuidados Críticos/métodos , Enfermedad Crítica , Manejo de la Enfermedad , Educación Médica Continua , Trasplante de Células Madre Hematopoyéticas , Humanos , Control de Infecciones/métodos , Control de Infecciones/normas , Oncología Médica/educación , Insuficiencia Multiorgánica/diagnóstico , Insuficiencia Multiorgánica/etiología , Neoplasias/complicaciones , Puntuaciones en la Disfunción de Órganos , Cuidados Paliativos/normas , Admisión del Paciente/normas , Grupo de Atención al Paciente , Pronóstico , Respiración Artificial , Insuficiencia Respiratoria/etiología , Insuficiencia Respiratoria/terapia , Índice de Severidad de la Enfermedad , Cuidado Terminal/normasRESUMEN
Fever is a symptom of a wide range of diseases. Its diagnostic management is of crucial importance, whereby the interface between general practitioner and hospital plays an important role. The family practitioner is of particular importance in the detection of life-threatening or complex situations involving fever. The diagnostic algorithm presented here can serve as the basis for rapid and targeted diagnostics. Good communication between the doctor and the hospital doctor is mandatory.
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Servicios Médicos de Urgencia , Medicina Familiar y Comunitaria , Fiebre de Origen Desconocido/diagnóstico , Fiebre de Origen Desconocido/etiología , Algoritmos , Enfermedades Autoinmunes/diagnóstico , Diagnóstico Diferencial , Fiebre de Origen Desconocido/inducido químicamente , Humanos , Infecciones/diagnóstico , Comunicación Interdisciplinaria , Colaboración Intersectorial , Neoplasias/diagnósticoRESUMEN
Immunosuppressive strategies applied in renal transplantation traditionally focus on T cell inhibition. B cells were mainly examined in the context of antibody-mediated rejection, whereas the impact of antibody-independent B cell functions has only recently entered the field of transplantation. Similar to T cells, distinct B cell subsets can enhance or inhibit immune responses. In this study, we prospectively analyzed the evolution of B cell subsets in the peripheral blood of AB0-compatible (n = 27) and AB0-incompatible (n = 10) renal transplant recipients. Activated B cells were transiently decreased and plasmablasts were permanently decreased in patients without signs of rejection throughout the first year. In patients with histologically confirmed renal allograft rejection, activated B cells and plasmablasts were significantly elevated on day 365. Rituximab treatment in AB0-incompatible patients resulted in long-lasting B cell depletion and in a naïve phenotype of repopulating B cells 1 year following transplantation. Acute allograft rejection was correlated with an increase of activated B cells and plasmablasts and with a significant reduction of regulatory B cell subsets. Our study demonstrates the remarkable effects of standard immunosuppression on circulating B cell subsets. Furthermore, the B cell compartment was significantly altered in rejecting patients. A specific targeting of deleterious B cell subsets could be of clinical benefit in renal transplantation.
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Sistema del Grupo Sanguíneo ABO/inmunología , Incompatibilidad de Grupos Sanguíneos/inmunología , Rechazo de Injerto/etiología , Supervivencia de Injerto/inmunología , Fallo Renal Crónico/cirugía , Trasplante de Riñón/efectos adversos , Receptores de Trasplantes , Adulto , Subgrupos de Linfocitos B/inmunología , Femenino , Estudios de Seguimiento , Rechazo de Injerto/sangre , Humanos , Inmunosupresores/uso terapéutico , Donadores Vivos , Masculino , Complicaciones Posoperatorias , Pronóstico , Estudios Prospectivos , Factores de Riesgo , Trasplante HomólogoRESUMEN
BACKGROUND: Febrile neutropenia remains one of the most common reasons for hospital admission of patients with underlying oncologic disease. These patients have an up to 10-fold increased risk of developing sepsis, which often leads to these patients being transferred to the intensive care unit (ICU). The survival of neutropenic patients with sepsis in particular has improved in recent years, due to advanced therapy in intensive care (surviving sepsis campaign); however few large international studies of neutropenic cancer patients in the ICU are available. METHODS: In a retrospective study, 59 episodes of neutropenic cancer patients in the internal medicine ICU at the University Hospital of Cologne over a period of 2 years were analyzed. RESULTS: Pneumonia with or without sepsis are the main admission diagnoses of neutropenic cancer patients in the ICU. The mortality rate of these patients is very high (50.8 %). Pneumonia and sepsis, stem cell transplantation, mechanical ventilation, and acute renal failure with or without dialysis are correlated with mortality. CONCLUSION: Cancer patients should be admitted immediately to the ICU if they have signs of sepsis for early monitoring and treatment. Neutropenic patients have an increased risk for infectious complications and a risk for sepsis with higher mortality rates.
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Neutropenia Febril Inducida por Quimioterapia/mortalidad , Neoplasias Hematológicas/tratamiento farmacológico , Neoplasias Hematológicas/mortalidad , Unidades de Cuidados Intensivos/estadística & datos numéricos , Adulto , Anciano , Anciano de 80 o más Años , Causas de Muerte , Neutropenia Febril Inducida por Quimioterapia/terapia , Femenino , Hospitales Universitarios , Humanos , Leucemia/tratamiento farmacológico , Leucemia/mortalidad , Linfoma/tratamiento farmacológico , Linfoma/mortalidad , Masculino , Persona de Mediana Edad , Infecciones Oportunistas/mortalidad , Infecciones Oportunistas/terapia , Neumonía/mortalidad , Neumonía/terapia , Estudios Retrospectivos , Factores de Riesgo , Sepsis/mortalidad , Sepsis/terapia , Estadística como Asunto , Adulto JovenRESUMEN
Allogeneic stem cell transplantation is a treatment option for patients with poor risk CLL. We conducted a retrospective analysis of all CLL patients allografted at our institution, the University Hospital of Cologne, Germany. Data was collected on 40 patients from 2004 to 2012. The mean age was 54, and the majority were male (75 %). On average, the patients were diagnosed 6 years (range 2-12) prior to transplant with an average of 4 years (range 1-8) from time of first-line therapy to transplant. The remission states at the time of transplant were complete remission (CR) (n = 4), stable disease (n = 10), partial remission (n = 20) and progressive disease (n = 6). Only reduced intensity conditioning regimens were employed. The average CD34(+) cell dose was 4.16 × 10(6)/kg. Neutrophil engraftment was seen by day +17 (range 10-23) post-transplant, and 88 % achieved 95-100 % donor chimerism by day 100. Overall survival, progression-free survival and non-relapse mortality at 2 years post-transplant were 65, 52.5 and 27.5 %, respectively. A total of 51 % of patients were found to be minimal residual disease (MRD)-negative at 1 year post-transplant. Our single-centre experience confirms the valuable role of allogeneic stem cell transplantation (allo-SCT) in the treatment of poor risk CLL patients with promising long-term survival and acceptable transplant-related mortality. The advent of newer therapeutic agents should not hinder the consideration of allo-SCT for this patient cohort as it remains the only curative option for these patients.
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Trasplante de Células Madre Hematopoyéticas/mortalidad , Leucemia Linfocítica Crónica de Células B/mortalidad , Leucemia Linfocítica Crónica de Células B/terapia , Adulto , Anciano , Femenino , Trasplante de Células Madre Hematopoyéticas/tendencias , Humanos , Leucemia Linfocítica Crónica de Células B/diagnóstico , Masculino , Persona de Mediana Edad , Morbilidad , Mortalidad/tendencias , Estudios Retrospectivos , Trasplante Homólogo/mortalidad , Trasplante Homólogo/tendencias , Resultado del TratamientoRESUMEN
The patient burden in intensive care units (ICU) has continually increased worldwide over the past decades. Age, co-morbidities and an increasing complexity of conditions and treatments increase the number of patients who are either colonized or infected with antibiotic-resistant pathogens. To prevent nosocomial infections, hygiene guidelines play an important role. In this paper, we investigate the time needed for nursing of five hypothetical critically ill patients in the intensive care unit. The results show that current staffing is not sufficient under the given hygiene guidelines and that a nurse to patient ratio of one will be necessary to meet the requirements. In a national survey of university hospitals, however, we found that the current nurse to patient ratio is 1: 2.47 in German intensive care units. The apparent staffing shortage is compensated by an extraordinary personal commitment of nurses caring for patients in the ICU.