Consensus statement for cancer patients requiring intensive care support.

This consensus statement is directed to intensivists, hematologists, and oncologists caring for critically ill cancer patients and focuses on the management of these patients.

[Short version S2e guidelines: "Positioning therapy and early mobilization for prophylaxis or therapy of pulmonary function disorders"]. / Kurzversion S2e-Leitlinie - "Lagerungstherapie und Frühmobilisation zur Prophylaxe oder Therapie von pulmonalen Funktionsstörungen".

The German Society of Anesthesiology and Intensive Care Medicine (DGAI) commissioned a revision of the S2 guidelines on "positioning therapy for prophylaxis or therapy of pulmonary function disorders" from 2008. Because of the increasing clinical and scientific relevance the guidelines were extended to include the issue of "early mobilization" and the following main topics are therefore included: use of positioning therapy and early mobilization for prophylaxis and therapy of pulmonary function disorders, undesired effects and complications of positioning therapy and early mobilization as well as practical aspects of the use of positioning therapy and early mobilization. These guidelines are the result of a systematic literature search and the subsequent critical evaluation of the evidence with scientific methods. The methodological approach for the process of development of the guidelines followed the requirements of evidence-based medicine, as defined as the standard by the Association of the Scientific Medical Societies in Germany. Recently published articles after 2005 were examined with respect to positioning therapy and the recently accepted aspect of early mobilization incorporates all literature published up to June 2014.

[Leukostasis and tumor lysis: important complications of hyperleukocytosis]. / Leukostase und Tumorlyse: Wichtige Komplikationen der Hyperleukozytose.

The occurrence of hyperleukocytosis (leukocytes > 100.000/µl) is associated with complications such as leukostasis, tumor lysis and consumption coagulopathy in patients with acute leukemia much more often than in patients with chronic malignant hematological diseases. To manage these situations may be complex as organ failure is often imminent or manifest, infectious complications arise and indications for induction chemotherapy are usually urgent. Prophylaxis and therapy of the tumor lysis syndrome consists of hydration, lowering of uric acid and the management of electrolyte disturbances. Leukostasis requires immediate reduction of the leukocyte count by leukapheresis, administration of hydroxycarbamide and, ultimately, by causative and specific treatment of the underlying disease itself. In patients with curable diseases or favorable long-term prognosis, transfer to the intensive care unit must be evaluated early in the course of impending organ dysfunction, especially in cases of acute respiratory failure.

Molecular analysis of the prevalent microbiota of human male and female forehead skin compared to forearm skin and the influence of make-up.

AIMS: To compare the bacterial diversity of two different ecological regions including human forehead, human forearm and to estimate the influence of make-up. METHODS AND RESULTS: Twenty-two swab-scraped skin samples were analysed by profiling bacterial 16S rRNA genes using PCR-based sequencing of randomly selected clones. Of the 1056 clones analysed, 67 genera and 133 species-level operational taxonomic units (SLOTUs) belonging to eight phyla were identified. A core set of bacterial taxa was found in all samples, including Actinobacteria, Firmicutes, and Proteobacteria, but pronounced intra- and interpersonal variation in bacterial community composition was observed. Only 4·48% of the genera and 1·50% of the SLOTUs were found in all 11 subjects. In contrast to the highly diverse microbiota of the forearm skin, the forehead skin microbiota represented a small-scale ecosystem with a few genera found in all individuals. The use of make-up, including foundation and powder, significantly enlarged the community diversity on the forehead skin. CONCLUSIONS: Our study confirmed the presence of a highly diverse microbiota of the human skin as described recently. In contrast to forearm skin, gender does not seem to have much influence on the microbial community of the forehead skin. However, the use of make-up was associated with a remarkable increase in the bacterial diversity. SIGNIFICANCE AND IMPACT OF THE STUDY: This study enhances our knowledge about the highly complex microbiota of the human skin and demonstrates for the first time the significant effect of make-up on the bacterial diversity of the forehead skin.

Material-dependent growth of human skin bacteria on textiles investigated using challenge tests and DNA genotyping.

AIMS: To investigate the influence of different fibre materials on the colonization of textiles by skin bacteria present in human sweat. METHODS AND RESULTS: The total bacterial content of axillary sweat samples was determined using DNA quantification, and the diversity of bacteria present was investigated. Fabrics made of different fibres were then challenged with these sweat samples; the bacterial DNA was quantified, and the bacterial taxa present were determined. We found differences in the overall colonization, with polyester and polyamide showing the highest bacterial mass. Also, significant differences in the various taxa of bacteria present on the different materials were found. In general, synthetic materials showed a selective growth of bacterial taxa underrepresented in sweat. In contrast, a cellulose-based material showed only very few taxa, identically with those predominant in sweat. CONCLUSIONS: Our investigations demonstrated that besides the bacterial content of sweat itself, the type of material has a strong impact on the bacterial colonization of textiles. SIGNIFICANCE AND IMPACT OF THE STUDY: Odour generation is one of several effects resulting from an interaction of skin bacteria with textiles, and it is a common experience that there are differences in odour generation by different materials. Our investigations suggest that a selective growth of potentially odour-producing bacteria may account for this.

[Extracorporeal lung support-news and future developments]. / Extrakorporale Lungenersatzverfahren ­ was gibt es Neues, was kommt?

Technical developments as well as the experiences during the 2009 influenza pandemia have led to an increased and safer use of extracorporeal gas exchange. Indications are expanding as new systems with the main goal of CO2 elimination have entered the market, thus, broadening the range of systems in addition to classic "high flow" extracorporeal membrane oxygenation (ECMO), although evidence for many suggested indications is sparse or lacking. However, recent research has shed light into the pathophysiology and interaction between the organism and the extracorporeal systems. Upcoming indications like avoiding intubation and mechanical ventilation or reducing invasiveness of ventilation are being evaluated. Novel data and technical advances will keep perspectives of extracorporeal gas exchange dynamic and exciting.

Correction to: S(+)-ketamine : Current trends in emergency and intensive caremedicine.

Correction to: Wien Klin Wochenschr 2017 https://doi.org/10.1007/s00508-017-1299-3 The article S(+)-ketamine Current trends in emergency and intensive caremedicine, written by Helmut Trimmel, Raimund Helbok, Thomas Staudinger, Wolfgang Jaksch, Brigitte Messerer, Herbert Schöchl and Rudolf Likar, was ….

[Extracorporeal membrane oxygenation : System selection, (contra)indications, and management]. / Extrakorporale Membranoxygenierung : Systemauswahl, (Kontra­)Indikationen und Management.

There are a large number of extracorporeal membrane oxygenation (ECMO) systems and configurations. Thorough planning and evaluation of specific therapeutic needs are necessary to tailor ECMO therapy to the individual patient situation. Indications tend towards lowering the threshold towards respiratory ECMO. Patients with severe acute respiratory distress syndrome (ARDS) not improving to optimization of ventilation and supportive therapeutic measures potentially qualify for ECMO. Contraindications are relative and have to be considered in the light of the individual risk-benefit ratio. The same is true for decisions to stop ECMO therapy in case of futility for which reliable evidence does not exist.

Subdural hygromas after bone marrow transplantation: results of a prospective study.

BACKGROUND: Subdural hygromas after bone marrow transplantation (BMT) have been occasionally found in patients with persisting headache and vomiting. We assessed the incidence of subdural hygromas after BMT and tried to define possible risk factors associated with this complication. METHODS: Fifty bone marrow graft recipients surviving more than 30 days were consecutively enrolled into a prospective study. Cranial CT scans were performed before and 30 days after BMT. Clinical data and symptoms were recorded daily during the first 30 days after BMT. In patients with subdural hygromas, a magnetic resonance imaging scan and monthly follow-up cranial computed tomography scans were performed until fluid collections had resolved completely. RESULTS: In 9 of the 50 patients (18%) who survived 30 days after transplantation, newly acquired subdural hygromas were found. Patients with hygromas suffered significantly longer and more severely from headache and vomiting (P=0.01). Application of intrathecal methotrexate and arterial hypertension occurred significantly more often in patients with hygromas (P=0.01). In a stepwise logistic regression model, arterial hypertension and intrathecal methotrexate application were the only independent risk factors for the development of hygromas. Monthly follow-up cranial computed tomography scans showed that all hygromas resolved completely after a median of 60 days after diagnosis (range: 30-120 days). CONCLUSIONS: Subdural hygromas are a frequent complication after BMT within the first 30 days after transplantation. They are reversible and disappear within 2-3 months. The need for routine application of intrathecal methotrexate in standard risk leukemia patients should be critically addressed. Furthermore, close monitoring of blood pressure and immediate antihypertensive therapy might contribute to avoid formation of subdural hygromas.

Successful management of adult respiratory distress syndrome (ARDS) after high-dose chemotherapy and peripheral blood progenitor cell rescue by non-invasive ventilatory support.

A 34-year-old man suffering from Hodgkin's disease underwent high-dose chemotherapy (CBV) followed by transplantation of autologous peripheral blood stem cells. On day +6 after peripheral blood stem cell transplant (PBSCT) bacterial pneumonia developed. Along with rapid engraftment during stimulation with G-CSF adult respiratory distress syndrome (ARDS) developed within 4 days. High-flow CPAP (continuous positive airway pressure) ventilation via a sealed face-mask was initiated. The patient tolerated the sealed face-mask very well, and CPAP was continuously administered for 4 days, thus avoiding intubation. High-flow CPAP may offer a therapeutic alternative in selected patients with respiratory compromise after PBSCT.

Experiences with severe P. falciparum malaria in the intensive care unit.

OBJECTIVE: To review the clinical profiles and therapies instituted for patients with severe malaria admitted to an ICU. DESIGN: Retrospective study. SETTING: Internal ICU of a tertiary care centre. PATIENTS AND PARTICIPANTS: Between January, 1992, and February, 1999, 104 patients with malaria were admitted to the General Hospital of Vienna. Sixty-nine patients suffered from Plasmodium falciparum malaria (66%), seven of these were admitted to the ICU. MEASUREMENT AND RESULTS: Seven patients were admitted to the ICU, of whom three died (4% in hospital case-fatality rate). Four patients required mechanical ventilation because of respiratory insufficiency and adult respiratory distress syndrome (ARDS), of whom three died. Three patients were treated with inhaled nitric oxide (NO) and kinetic therapy; one patient required extracorporeal veno-venous oxygenation. All patients who died required haemofiltration because of acute renal failure. CONCLUSION: As P. falciparum is a potentially life-threatening disease, reliable criteria for ICU admission should be defined and risk factors identified. Early ICU monitoring should be attempted, especially under the following conditions: (1) lack of clinical response to anti-malarial treatment within 48 h and/or (2) any signs of neurological disturbance (hypoglycaemia excluded). Prospective multicentre trials and guidelines for supportive intensive care are urgently needed.

Plasma exchange for treatment of thrombotic thrombocytopenic purpura in critically ill patients.

OBJECTIVE: Description of diagnostic procedures, treatment modalities and intensive care management of patients with thrombotic thrombocytopenic purpura (TTP). DESIGN: Descriptive study. SETTING: Internal medicine Intensive Care Unit (University Hospital of Vienna). PATIENTS: Six patients (two after allogeneic bone marrow transplantation), treated for 12 episodes of TTP. INTERVENTIONS: Treatment with plasma exchange (fresh frozen plasma, 50-80 ml/kg per day), prednisone (0.75 mg/kg b.i.d.) and, in some cases, vincristine. Supportive therapy as needed. MEASUREMENTS AND RESULTS: Patients were admitted to the ICU because of neurological symptoms with acute onset (42% mild, 58% severe), hemolysis and thrombocytopenia. Additional symptoms were fever (50%), bleeding tendency (50%), acute renal failure (42%) and metabolic derangement (8%). Initial laboratory values showed thrombocytopenia (median 17 G/l), hemolysis (median hemoglobin 10.0 g/dl, lactate dehydrogenase 635 U/l, reticulocyte count 175 G/l) with red cell fragmentation. Coagulation tests were normal. Respiratory assist was needed in six episodes (severe seizures, cardiopulmonary resuscitation). In patients without preexisting hematological abnormality the platelet counts exceeded 100 G/l after 3-8 cycles of plasma exchange. In patients after bone marrow transplantation, the platelet counts never exceeded 40 G/l, but the lactate dehydrogenase levels dropped significantly. The neurological symptoms disappeared in all patients and renal function normalized. One patient died before the initiation of therapy. Three patients relapsed 1-3 times between 2 weeks and 5 months after the last episode. The relapses were associated with symptoms similar to the first episode and responded promptly to plasma therapy. CONCLUSIONS: TTP is a rare, but life-threatening disorder. It needs immediate diagnosis and has a good prognosis after adequate treatment with plasma exchange.

Influence of pentoxifylline on cytokine levels and inflammatory parameters in septic shock.

OBJECTIVE: To evaluate the influence of pentoxifylline (PTX), a phosphodiesterase inhibitor, on cytokines and inflammatory proteins in patients suffering from septic shock. DESIGN: Prospective study comparing a therapy group to a matched control group. SETTING: Medical intensive care unit at a university hospital. PATIENTS: Twenty four patients fulfilling the criteria of septic shock were included in this study. Twelve patients received PTX (therapy group) and 12 patients matched for diagnosis, age and gender served as the control group. INTERVENTIONS: Pentoxifylline at 1 mg/kg per hour over 24 h in the therapy group. MEASUREMENTS AND RESULTS: Cytokine levels [tumor necrosis factor-alpha (TNF)], soluble TNF receptor [TNF-R], and interleukin-6 [IL-6] and inflammatory proteins [C-reactive protein, alpha-1-antitrypsin (AAT), fibronectin, and haptoglobin], as well as hemodynamic parameters and the APACHE III score were evaluated before initiation of therapy and 24 h-later. After 24 h, TNF levels were significantly lower in the therapy group (p = 0.013), while IL-6 levels were significantly higher in the therapy group (p = 0.030). Within the 24 h TNF declined significantly in the therapy group (p = 0.006), while IL-6 showed a significant increase (p = 0.043). AAT and the APACHE III score tended to differ significantly after 24 h between the groups [AAT levels higher in the therapy group (p = 0.05), APACHE III score lower (p = 0.05)]. In the therapy group, the systemic vascular resistance index was significantly higher after 24 h (p = 0.0026) whereas the cardiac index declined (p = 0.035). CONCLUSIONS: PTX does influence TNF levels in septic shock patients. Nevertheless, inhibiting a single mediator in severe septic shock cannot stop the inflammatory overreaction.

Influence of prothrombin complex concentrates on plasma coagulation in critically ill patients.

OBJECTIVE: To evaluate thrombogenicity of prothrombin complex concentrates (PCCs) in critically ill patients. DESIGN: Prospective clinical study. SETTING: Medical intensive care unit at a university hospital. PATIENTS: 16 consecutive patients suffering from acquired deficiencies of coagulation factors and with either overt bleeding from any site or a planned invasive procedure. INTERVENTIONS: 2000 factor IX units of PCCs intravenously. MEASUREMENTS AND RESULTS: Prothrombin time (PT), activated partial prothrombin time, fibrinogen, platelet count, plasma levels of coagulation factors II, V, VII, VIII, IX, X, antithrombin, protein C, thrombin-antithrombin complex (TAT), prothrombin fragment F(1+2), and the fibrin degradation product D-dimer were measured prior to and 1, 3, and 24 h after administration of PCCs. PT as well as coagulation factors II, VII, IX, and X, TAT, and F(1+2) showed a significant increase after administration of PCCs. All other parameters remained unchanged. CONCLUSIONS: Administration of PCCs induces thrombin generation. No evidence for induction of disseminated intravascular coagulation in biochemical terms could be found. When rapid correction of acquired coagulation factor disturbances is warranted, the use of PCCs seems reasonable, but the elevated risk of intravascular thrombus formation should be kept in mind.

Contamination of central venous catheters in immunocompromised patients: a comparison between two different types of central venous catheters.

Catheters impregnated with silver have been proposed as a means of reducing catheter-related infection. We therefore performed a prospective randomized study to compare a new silver-impregnated central venous catheter (CVC) with a commercially available CVC in a cohort of immunocompromised patients. We studied 157 patients of whom 97 could be analysed. The median indwelling time in the study group (SC) was 10.5 days and 11 days in the control group (CC). The incidence of contamination in the SC group was 15.6 vs 24.6 in the CC group referring to 1000 catheter days. In both groups, we found 6% of catheter-related infections according to the definitions of a published scoring system. The differences between the two groups were not significant. We conclude that the SC decrease the incidence of catheter contamination and may have a positive effect on the reduction of CVC-related infections.

Emergency intubation with the Combitube in a grossly obese patient with bull neck.

A grossly obese patient with bull neck required immediate intubation. Endotracheal intubation failed because visualization of the vocal cords was not possible. As an alternative, the Combitube was inserted without difficulty and the patients lungs were ventilated via the Combitube until tracheotomy was performed on the following day. The patient survived and was discharged alive from the hospital 5 weeks later. The Combitube has gained worldwide interest and is now included in the Guidelines of the American Heart Association and the American Society of Anesthesiologists.

Exogenous surfactant therapy in a patient with adult respiratory distress syndrome after near drowning.

A 24-year-old woman developed adult respiratory distress syndrome (ARDS) after near-drowning due to attempted suicide. Conventional mechanical ventilation together with prone positioning and inhaled nitric oxide could not provide sufficient oxygenation. Surface tension data (gamma min = 27 dyn/cm, stability index = 0.341) from a lavage sample supported the hypothesis that the surfactant function of this patient was drastically reduced due to a washout effect by aspiration of fresh water. Porcine surfactant (Curosurf, 50 mg/kg for each lung) was instilled via fibreoptic bronchoscope. The partial arterial carbon dioxide pressure (paCO2) and fraction of inspired oxygen (FiO2) ratio as well as shunt fraction (Qs/Qt) improved impressively. When respiratory situation deteriorated again, surfactant application was repeated. Altogether, six bolus instillations of surfactant (total dose 300 mg/kg = 18,000 mg) were administered until the respiratory situation had stabilized and oxygenation could be maintained by conventional mechanical ventilation. The radiological findings did not show substantial amelioration. The patient developed septic shock and died 12 days after admission. Surfactant application apparently led to a significant improvement of the respiratory function. However, the outcome could not be influenced positively. The high cost of surfactant therapy prevents the more widespread early administration in patients at risk.

Pharmacokinetics of teicoplanin during continuous hemofiltration with a new and a 24-h used highly permeable membrane: rationale for therapeutic drug monitoring-guided dosage.

OBJECTIVE: Continuous venovenous hemofiltration (CVVH) is widely used in the management of critically ill patients, but only few administration guidelines for antimicrobial drugs are available. It is unclear whether the use of a filter for more than 24 hours might lead to less efficient extraction. This study describes the pharmacokinetics of teicoplanin during CVVH using a highly permeable membrane. METHODS: Pharmacokinetics of teicoplanin during continuous hemofiltration with a new (group 1) and a 24-h used (group 2), highly permeable polyamide membrane were assessed in 3 patients. RESULTS: The teicoplanin serum concentrations (44.0 +/- 18.5 mg/l vs 109.5 +/- 34.5 mg/l) and half-life of teicoplanin (4.6 +/- 1.1 h vs 5.2 +/- 0.7 h) differed significantly between the 2 groups indicating a smaller elimination of the drug on the second day. Substantial binding of teicoplanin to filter membranes could explain this observation. CONCLUSION: The results suggest that daily adjustment of the dosage is necessary to achieve sufficient teicoplanin concentrations and a fixed dosage recommendation is not suitable for this drug.

Hypothyroidism as a cause of tacrolimus intoxication and acute renal failure: a case report.

The nephrotoxic side effects of cyclophilin-binding agents like cyclosporine A and tacrolimus are well characterized. In severe cases nephrotoxicity may profoundly deteriorate kidney function and even induce acute renal failure. In this report we describe the first case of excessive tacrolimus intoxication caused by hypothyroidism. The patient had undergone single-lung transplantation 6 months earlier, developed hypothyroidism, and was admitted with acute anuric renal failure. Thyroxin is a potent activator of the cytochrome P-450- CYP 3A enzyme system, which is crucial for tacrolimus metabolism. Hence, hypothyroidism reduces cytochrome P-450 activity and may result in drug accumulation. Rapid reversal of toxic drug levels could be achieved by reducing drug intake and increasing thyroxin levels by substitution therapy. In conclusion, it is important to consider thyroid function when prescribing medications with a narrow therapeutic range, which are metabolized by the cytochrome P-450 system such as tacrolimus, and the possible devastating effect of impaired drug metabolism during hypothyroidism.

[Comparison of the Combitube with the endotracheal tube in cardiopulmonary resuscitation in the prehospital phase]. / Vergleich des Combitube mit dem Endotrachealtubus während kardiopulmonaler Reanimation in der Prähospitalphase.

A prospective controlled study was undertaken to evaluate the efficacy of the Combitube, a combined endotracheal and esophageal obturator airway adjunct, in prehospital cardiac arrest patients. The Combitube and a standard endotracheal tube were utilized on alternate days as the initial airway of choice by paramedics. Of altogether 86 patients treated during the study period, intubation was possible in 80 cases, 38 receiving a Combitube as initial choice of airway. 11 out of 14 patients who could not be intubated with a standard endotracheal tube were then successfully managed with a Combitube. Survival following cardiac arrest after insertion of a Combitube was comparable to conventional endotracheal intubation. Of the 6 patients who survived 2 had received a Combitube, 2 a standard endotracheal tube and 2 an oropharyngeal tube. While visualized endotracheal intubation remains the preferred method of airway control, the Combitube is an effective airway as backup to the endotracheal tube, as well as a primary airway, especially outside hospital. Contraindications are listed.