[Expert systems-urgently needed for early diagnosis of sepsis : Results of retrospective clinical validation of the expert system FLORIDA]. / Expertensysteme ­ dringendes Erfordernis für die Frühdiagnostik der Sepsis : Ergebnisse einer retrospektiven klinischen Validierung des Expertensystems FLORIDA.

The expert system FLORIDA (Fuzzy Logic Orientated Rule Interpreter for Diagnostic Applications) is equipped with a knowledge base applying linguistic rules of clinical experts according to the pathophysiologic conception of the sepsis-3 definition and the mathematics of fuzzy logic. It works independently of any subjective factors. FLORIDA detects sepsis by an increase of a second incoming value ≥ 25% compared with the reference value. It requires dynamics of the parameters used in knowledge base; thus, if the dynamics are absent, the system is unable to detect sepsis. In a retrospective clinical validation study, FLORIDA was used to scan 498 consecutive patients in a medical intensive care unit, which corresponded to 1700 patient-days. During the study period, the prevalence of sepsis was 10%. In all, 423 patients were identified as not having sepsis, which was confirmed by clinical experts. Among the 48 patients identified as having sepsis, 26 were confirmed (true positive). In 22 patients, sepsis could not be confirmed by the clinician (false positive). FLORIDA did not detect sepsis in 4 patients, but was diagnosed by the clinician (false negative). In the 22 false-positive patients, a life-threatening disease existed requiring intensive care. Because of the system philosophy, FLORIDA is unable to recognize patients with full blown sepsis at admission. With this in mind, the sensitivity was 1.0 and specificity was 0.95. Thus, FLORIDA is qualified for the early detection of a developing sepsis. Sepsis is detected on average 12.5 ± 8.6 h after the start of sepsis has been determined by a clinical expert. FLORIDA should be used on normal wards and should contribute to early detection of sepsis and potentially earlier therapeutic intervention in order to decrease hospital mortality. However, prospective validation is needed.

[Blood pressure monitoring - Status quo and future : A contribution to the personalized medicine]. / Blutdruckmonitoring ­ Status quo und Ausblick : Ein Beitrag zur personalisierten Medizin.

Sustainment of life demands that the heart create sufficient pressure to maintain enough flow to keep the body healthy and oxygenated. Blood pressures can be easily measured, while volume measurements required additional invasive procedures. In analogy to volumetrically determined ejection fraction, a pressure ejection fraction EF(P) may be calculated. When standardized to heart rate and body surface area, a new, effective performance metric may be defined. These metrics enable the long-term monitoring of the critically ill patient. When presented in a performance diagram, the metrics contain prognostic implications and enable a real-time evaluation of the efficacy of therapeutic measures. Until now, pressure-related prognostic statements were based on statistical averages, which by definition apply to groups. With this new analytical approach, we have the ability to provide patient-specific therapeutics in an area of medicine that requires individualized treatment. Here, we show preliminary results of applying a mathematical risk analysis to blood pressure metrics to assess therapeutic risk.

[Tarragona strategy--appropriate antibiotic therapy in the ICU]. / "Tarragona-Strategie"--adäquate Antibiotikatherapie auf der Intensivstation.

BACKGROUND: Appropriate antibiotic initial therapy remarkably decreases the mortality of patients with infections in the ICU. The establishment of an appropriate initial therapy follows empirical aspects. This practice was first done for the treatment of nosocomial pneumonia. Since that time the practice became known as Tarragona strategy. RESULTS: The basic elements of the strategy are based on the initial antibiotic treatment of patients with infections in the ICU in general and include the following: view the patient and his/her medical history, consider the microbiologic environment, in which the patient became ill, test for possible causative microorganisms and initiate high-dose antibiotics immediately, evaluate pharmacokinetic/pharmacodynamic aspects influenced by the pathophysiologic processes in the critically ill patient, the specifics of the microorganisms, the peculiarity of the antibiotics in the patient and due to therapeutic procedures, and tailor the initial broad spectrum therapy as necessary according to the microbiological results. CONCLUSION: This procedure is safe, reduces mortality, limits the development of resistance, and is economic.

Ejection fractions and pressure-heart rate product to evaluate cardiac efficiency. Continuous, real-time diagnosis using blood pressure and heart rate.

INTRODUCTION: Ejection fractions, derived from ventricular volumes, and double product, related to myocardial oxygen consumption, are important diagnostic parameters, as they describe the efficiency with which oxygen is consumed. Present technology often allows only intermittent determination of physiological status. This deficiency may be overcome if ejection fractions and myocardial oxygen consumption could be determined from continuous blood pressure and heart rate measurements. The purpose of this study is to determine the viability of pressure-derived ejection fractions and pressure-heart rate data in a diverse patient population and the use of ejection fractions to monitor patient safety. METHODS: Volume ejection fractions, derived from ventricular volumes, EF(V), are defined by the ratio of the difference of end-diastolic volume, EDV, and end-systolic volume, ESV, to EDV. In analogy, pressure ejection fraction, EF(P), may be defined by the ratio of the difference of systolic arterial pressure, SBP, and diastolic arterial pressure, DBP, to SBP. The pressure-heart rate (heart rate: HR) is given by the product of systolic pressure and heart rate, SBP × HR. EF(P) and SBP × HR data were derived for all patients (n = 824) who were admitted in 2008 to the ICU of a university hospital at the specific time 30 min prior to leaving the ICU whether as survivors or non-survivors. The results are displayed in an efficiency/pressure-heart rate diagram. RESULTS: The efficiency/pressure-heart rate diagram reveals one subarea populated exclusively by survivors, another subarea populated statistically significant by non-survivors, and a third area shared by survivors and non-survivors. DISCUSSION AND CONCLUSION: The efficiency/pressure-heart rate product relationship may be used as an outcome criterion to assess survival and to noninvasively monitor improvement or deterioration in real time to improve safety in patients with diverse dysfunctions.

[Thrombophilic states in intensive care medicine]. / Thrombophile Zustände in der Intensivmedizin.

Thrombophilic states are common in intensive care medicine. Generally, they are complications of serious underlying diseases or adverse effects of treatment measures. The attributive mortality rate for thrombophilic states is high. Early recognition and management are, thus, indispensable. In this review, important diagnostic and therapeutic aspects are briefly summarized. Leading symptoms and the context to the underlying disease or therapy, which result in a thrombophilic state, are the basics for a specific diagnostic workup. Almost all current treatment recommendations are based on expert opinion.

[A 49-year-old woman with deep vein thrombosis, pulmonary embolism, and left-sided paralysis]. / 49-jährige Patientin mit tiefer Beinvenenthrombose, Lungenembolie und linksseitiger Hemiparese.

We report the case of a 49-year-old female patient who was admitted stationary because of a left-sided paralysis which had appeared some hours before. An embolic occlusion of the right A. cerebri media turned out to be the cause. A paradoxical embolism could be assumed because of an existing deep vein thrombosis and an increased right-ventricular pressure within a hemodynamically relevant fulminant pulmonary embolism as well as the additional existence of a patent foramen ovale (PFO). Systemic lysis as treatment of the pulmonary embolism was contraindicated because slight bleeding had occurred in the area of the right basal ganglia after treatment of the embolic occlusion of the right A. cerebri media by a local lysis. Subsequently and in the acuteness, a catheter interventional PFO-closure via a double-umbrella device was placed and the pulmonary embolism was effectively treated by a local lysis through the insertion of a pigtail-catheter into the right pulmonary artery.

[The design of the VISEP trial. Critical appraisal]. / Studienprotokoll der VISEP-Studie. Eine kritische Stellungnahme.

The survey transcript of the VISEP interventional trial "Prospective randomized multicenter study on the influence of colloid vs crystalloid volume resuscitation and of intensive vs conventional insulin therapy on outcome in patients with severe sepsis and septic shock" [Clinical trials.gov. identifier: NCT00135473; study start April 2003] comprises, according to the data of the year 2003, methodological shortcomings which challenge a priori the study design and thus the resolution of the purpose of the study, i.e., "determination of the influence of the studied volume and insulin interventions on morbidity and mortality of patients with severe sepsis and septic shock". The most important points of criticism are: 1. A volume therapy with exclusively crystalloids or colloids with the chosen colloid hyperoncotic, hyperchloremic HES solution (10% hydroxyethyl starch: 10% Hemohes) or the crystalloid solution with high lactate content (Sterofundin) is neither acceptable nor practicable, even if only due to exceeding the maximum dosage as recommended by the manufacturer. 2. The fact known since the year 2001 that high molecular weight, poorly biodegradable HES preparations can present an independent risk-factor for acute kidney failure in patients with sepsis or septic shock was ignored: the exclusion criterion of a serum-creatinine value of >320 micromol/l (>3.6 mg/dl) was doubled in relation to the manufacturer's specification. 3. The hyperoncotic colloid solution used (10% Hemohes) may only be employed for a brief period: it is highly hyperchloremic and causes extravascular hypohydration with consecutive reduction of renal excretion, which together with HES is a fatal combination. 4. The crystalloid solution used, i.e., Sterofundin, which contains 45 mmol/l lactate, is contraindicated with septic shock as it increases the patient's O2 consumption, hinders lactate diagnostics as a hypoxia marker by simultaneous lactate infusion, and through increased gluconeogenesis leads to hyperglycemia, at least with diabetics. 5. It is doubtful whether an intensified insulin therapy (Actrapid) can be successful if insulin is administered simultaneously with iatrogenic hyperglycemia as a result of lactate influx. Due to these flaws in the design of the VISEP trial, the only consequence can be that the results of the survey are unusable, especially with regard to the point "HES and kidney function". Thus, any further advance presentations and interpretations should be shelved in expectation of the authors' publication of all the data, in order to begin further discussions including the flaws in study design listed here.