[Nutritional therapy in traumatic brain injury : Update 2012]. / Ernährungstherapie bei Schädel-Hirn-Trauma : Update 2012.

Severe traumatic brain injury ranks among the most common causes of death in young adults in western countries. Severe traumatic brain injury is typically followed by a pronounced pathophysiological cascade that accounts for many deaths. The aim of intensive care medicine after traumatic brain injury is to minimize and to control the consequences of this potentially fatal cascade. The avoidance of hypoxemia, arterial hypotension, intracranial hypertension, hyperthermia, hyperglycemia, hypoglycemia and thromboembolic complications is essential in preventing this cascade. The effect of nutrition has been rather underestimated as a means of improving the outcome after traumatic brain injury. Nutrition should be started within the first 24 h after trauma. Enteral, wherever applicable, should be the route of administration of nutrition. Enteral administration of the whole calculated calorie requirement on day 1 after trauma, if possible, lowers the infection and overall complication rates. The present review gives an update of a practical approach to nutrition in traumatic brain injury.

Emergency extracorporeal membrane oxygenation to treat massive aspiration during anaesthesia induction. A case report.

Since first described in 1946 by Mendelson, aspiration of gastric content resulting in severe pulmonary complications is a known hazard of general anaesthesia. We report on a case of massive aspiration of gastric content during induction of general anaesthesia, resulting in severe prolonged hypoxaemia with cardiac arrest, followed by rapid onset of an acute respiratory distress syndrome (ARDS) associated with severe global respiratory insufficiency and severe hypoxia. ARDS was successfully treated using emergency extracorporeal membrane oxygenation within 3 h after the incident.

[Anesthesiological management of Caesarean sections : nationwide survey in Germany]. / Anästhesiologisches Management der Sectio caesarea : Deutschlandweite Umfrage.

BACKGROUND: The rate of Caesarean sections in Germany continues to rise. The change in anesthetic technique of choice from general to spinal anesthesia began later than in other countries and at the last survey in 2002 was not widely established. The literature on the anesthetic management of Caesarean sections contains many controversies, for example fluid preload before performing spinal anesthesia and the vasopressor of choice. Other issues have received relatively little attention, such as the level of experience of anesthesiologists working autonomously on the labour ward or the timing of antibiotic prophylaxis. The aim of the current survey was to provide an updated overview of anesthetic management of Caesarean sections in Germany. MATERIAL AND METHODS: A questionnaire was sent out to 709 departments of anesthesiology serving obstetric units in Germany. The questionnaire concerned various aspects of anesthetic management of Caesarean sections. RESULTS: A total of 360 questionnaires (50.8%) were returned of which 346 were complete and could be analyzed, accounting for 330,000 births and 90,000 Caesarean sections per year. The predominant anesthetic method used for Caesarean sections was spinal anesthesia (90.8%) using hyperbaric bupivacaine and in approximately one third of the hospitals surveyed without administering intrathecal opioids. Approximately 12% of the departments surveyed used traumatic Quincke needles. In 86.2% the vasopressor of choice was caffedrine/theodrenaline. Nitrous oxide was used in only 19.2% of departments surveyed when general anesthesia is performed. An antibiotic drug was administered in only 11% of hospitals before cord clamping. In 43.1% no neonatologist was available to treat unexpected critically ill newborns. In 32.1% of departments surveyed residents with less than 2 years experience worked autonomously on the labour ward. CONCLUSIONS: Currently the predominant anesthetic technique of choice in Germany is spinal anaesthesia and at a much higher rate than in 2002. In addition 12% of departments use traumatic Quincke needles which are associated with a higher incidence of postpuncture headache. Nitrous oxide is no longer frequently used in Germany. Finally, the administration of an antibiotic before cord clamping has been shown to lead to lower rates of endometritis and postoperative wound infection without detrimental effects on the newborn. This is practiced in only a small minority of departments across Germany.

[Severe airway distress following cervical spine operation: retrospective breakdown of the chain of errors]. / Dramatischer Atemwegsnotfall nach Operation an der Halswirbelsäule : Retrospektive Analyse der Fehlerkette.

A 71-year-old female patient received a prothesis due to a cervical disc prolapsed and bleeding into the collar soft tissues occurred postoperatively. Following a computed tomography examination severe peracute respiratory decompensation occurred while administering topical anesthesia to the pharynx in order to perform fiber optic intubation. Endotracheal intubation using conventional laryngoscopy was unsuccessful and the patient required immediate cricothyroidotomy. As an on-site cricothyrotomy set to establish a secure airway was not available the decision was taken to perform surgical cricothyroidotomy. As a conclusion to this life-threatening event in the case of symptoms, such as dyspnea, dysphonia and dysphagia after operations of the cervical spine the airway has to be secured early and according to the local algorithm.

Pain, postdural puncture headache, nausea, and pruritus after cesarean delivery: a survey of prophylaxis and treatment.

BACKGROUND: The need for a cesarean delivery may interfere negatively with the overall experience of childbirth. Several factors related to anesthesiological management such as postoperative pain and discomfort, nausea and pruritus, and postdural puncture headache (PDPH), may lead to dissatisfaction and have a negative impact on early mobilization and a new mother's ability to care for her newborn baby. Optimal prophylaxis and treatment decrease these complications, increase satisfaction, and prevent chronic pain. This survey determined how prophylaxis and treatment of pain, PDPH, nausea, and pruritus after cesarean section (CS) is managed. METHODS: A questionnaire was sent to 709 departments of anesthesiology serving an obstetric unit in Germany. The questionnaire asked about different aspects of pain management, the management of accidental dural puncture (ADP), and treatment of PDPH. Further we asked about therapy and prophylaxis of nausea and pruritus in the peripartal setting. RESULTS: In all, 360 questionnaires (50.8%) were returned; 346 were complete and analyzed (accounting for 330000 births per year). Paracetamol (77.5%) and piritramide (85.6%) are the most common analgesics used. If epidural catheters were used for anesthesia for CS, 47.7% were used for postoperative pain therapy. However, 92.7% of the departments removed catheters in less than 24 hours after delivery. In case of an ADP most departments (69.9%) repeated puncture, 2.6% placed catheters intrathecally. Median blood volume for an epidural blood patch was 10ml. CONCLUSION: Apart from conservative treatment of PDPH, prophylaxis and treatment of pain after cesarean delivery, PDPH, nausea, and pruritus varied widely, indicating the need for the qualitative evaluation of overall management.

Lipid therapy for serotonin syndrome after intoxication with venlafaxine, lamotrigine and diazepam.

A 44-year-old woman developed coma and seizure activity after intentional ingestion of 200 mg diazepam, 20 g lamotrigine and 4.5 g venlafaxine. In our intensive care unit a distinct rigidity and hyperreflexia was observed. This status was not influenced by haemodialysis which was initiated directly after admission. Plasma concentrations of the ingested drugs were determined before hemodialysis was started (560 µg/L diazepam, 42.4 mg/L lamotrigine and 1254 µg/L venlafaxine). Eight hours after the start of haemodialysis a 150 mL (2.5 mL/kg) intravenous bolus of 20% lipid emulsion was given. Soon after administration of the lipid infusion the distinct rigidity and hyperreflexia disappeared. The further course was uneventful.

[Thrombolysis during cardio-pulmonary resuscitation]. / Thrombolyse während der kardiopulmonalen Reanimation.

Sudden cardiac death is a leading cause of death in Europe. In the vast majority, myocardial infarction or pulmonary embolism is the underlying cause. Lethality is still high, especially if the arrest occurs out of hospital. For these two severe conditions, thrombolysis has proven to be an established therapy. Coronary perfusion is restored or the occlusion in the pulmonary arteries is removed, restoring normal circulation and normalising right-ventricular afterload. Nevertheless, thrombolysis was contraindicated during cardio-pulmonary resuscitation (CPR) for many years due to the fear of severe bleeding complications. Case reports and series using thrombolysis as successful ultima ratio therapy during prolonged CPR were soon followed by retrospective and interventional studies. These trials showed significantly improved survival for patients after thrombolysis during CPR. Nevertheless, none of these trials was randomised. Other trials showed that bleeding complications do not occur more frequently after thrombolysis during CPR. Experimental investigations demonstrated that thrombolysis during CPR improves cerebral microcirculation. The results of the randomised, multicenter trial TROICA show that tenecteplase alone, does not significantly improve survival. Further studies on thrombolysis during CPR with additional administration of heparin and acetylsalicylic acid must follow to ascertain the role of thrombolysis during CPR. Although thrombolysis during CPR is not a standard therapy, it should not be withheld from patients in whom pulmonary embolism is the suspected cause of cardiac arrest, as well as in selected other patients on the physician's individual decision according to recent guidelines.

Survey on the use of oxytocin for cesarean section.

BACKGROUND: The administration of oxytocin at high doses during cesarean section may cause severe cardiovascular complications. However, a dosage as low as 1 IU has been proven to suffice. Bolus administration is not superior to infusion and causes more severe side effects. The purpose of this survey was therefore to determine dosages and routes of administration of oxytocin during cesarean section in Germany. METHODS: A questionnaire was sent to 709 departments of anesthesiology. The questionnaire asked about the standard dosage of oxytocin and route of administration (bolus and/or slow infusion) used for cesarean section. RESULTS: A total of 360 questionnaires (50.8%) were returned; 346 of these were filled out and therefore analyzed (accounting for approximately 329,000 births). It was found that 295 (85.3%) departments administer oxytocin as a bolus, and 48 (13.9%) give it only as a slow infusion. A bolus of 1-3 IU is administered at 176 departments (51.8%), 5-9 IU at 71 (20.9%), 10 IU at 39 (11.6%), and 12-40 IU at 6 (1.8%). Additionally, 3-9 IU were slowly infused at 56 departments (16.7%), 10 IU at 174 (50.3%), 12-20 IU at 51 (14.7%), and 23-40 IU at 22 (6.4%). The median cumulative oxytocin dose is 13 IU, ranging from 1 to 80 IU. CONCLUSION: Most of the responding departments give oxytocin as a bolus at a relatively low dose. However, despite the potentially fatal side effects, one out of eight departments administers 10 IU or more as a bolus.

Selective inhibition of guanylate cyclase prevents impairment of hypoxic pulmonary vasoconstriction in endotoxemic mice.

Nitric oxide (NO) may cause sepsis-induced impairment of hypoxic pulmonary vasoconstriction (HPV). Although NO exerts many of its actions by activating soluble guanylate cyclase (sGC), there are several cGC-independent mechanisms that may lead to NO-induced vasodilation during endotoxemia. We investigated the role of sGC for the regulation of HPV during lipopolysaccharide (LPS) induced endotoxemia using 1H-(1,2,4)oxadiazole(4,3-alpha)quinoxaline-1-one (ODQ), a specific inhibitor of sGC, in isolated, perfused, and ventilated mouse lungs. Without ODQ, lungs from LPS-challenged mice constricted significantly less in response to hypoxia as compared to lungs from mice not treated with LPS (26 +/- 27% vs. 134 +/- 37%, respectively, p < 0.05). 20 mg/kg ODQ, but not 2 mg/kg or 10 mg/kg, restored the blunted HPV response in LPS-challenged mice as compared to mice not challenged with LPS (80+/-14 % vs. 98+/-21 %). ODQ had no effect on baseline perfusion pressures under normoxic conditions. Analysis of pulmonary vascular P-Q relationships suggested that the restoration of pulmonary vascular response to hypoxia by ODQ is associated with a restoration of pulmonary vascular properties during normoxia. Our data show in a murine model that specific inhibition of sGC may be a new approach to restore HPV during endotoxemia.

[Accidentally opened adjustable pressure-limiting valve. Failure of manual ventilation]. / Unbemerkt geöffnetes "Adjustable-pressure-limiting"-Ventil: Unmöglichkeit der manuellen Beatmung.

In the case presented successful induction of anaesthesia was followed by failure to ventilate a patient during anaesthesia caused by a leakage in the anaesthesia circuit system during manual ventilation. The leakage problem could not be solved after checking the classical leakage sites (blocked tube, filter and tubes) and was due to a gas sensing line that caused a malfunction of the adjustable pressure-limiting valve.

[Thrombolysis in cardiopulmonary resuscitation]. / Thrombolyse während kardiopulmonaler Reanimation.

The prognosis of patients suffering cardiac arrest is still poor. Until today, no drug therapy has shown to improve longterm survival after cardiac arrest. Thrombolysis has been shown to be an effective therapy in patients with acute myocardial infarction (AMI) or massive pulmonary embolism (PE). Since 50-70% of cardiac arrests are caused by AMI or massive PE, the combination of cardiopulmonary resuscitation (CPR) and thrombolytic therapy appears to be sensible. As experimental studies have shown, thrombolytic therapy during CPR may not only be a causal treatment for coronary or pulmonary arterial obstruction by thrombi, but may also improve microcirculatory reperfusion after cardiac arrest. Although numerous small clinical studies have shown the efficacy of thrombolysis during CPR in selected patients, the generalized treatment of patients suffering cardiac arrest with thrombolytics can not be recommended based on current clinical evidence. According to the recent CPR guidelines, thrombolysis may be considered in cardiac arrest patients with suspected massive PE or as a so-called rescue therapy after unsuccessful conventional CPR in patients with a suspected thrombotic cause of cardiac arrest. The risk of severe bleeding complications following thrombolysis during CPR seems to be outweighed by the potential benefit of this therapy in selected patients.

Comparison of two methods for enhanced continuous circulatory monitoring in patients with septic shock.

OBJECTIVE: To compare a modified pulmonary artery catheter (PAC) and pulse-contour analysis by the PiCCO (Pulsion Medical Systems, Munich, Germany) system for continuous assessment of cardiac output in patients with septic shock. In addition, to assess the relationships between an index of global end-diastolic volume (GEDV) derived by the PiCCO system with traditional PAC-derived indicators of filling: central venous pressure; pulmonary artery occlusion pressure; and right ventricular end-diastolic volume (RVEDV). DESIGN: Prospective cohort study. SETTING: Surgical intensive care unit of a university hospital. PATIENTS AND PARTICIPANTS: 14 patients with septic shock. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: A significant correlation was found between continuous cardiac output by PAC (CCO(PAC)) and by pulse-contour analysis (r (2) = 0.714, p < 0.0001), accompanied by a bias of 0.1 l min(-1) and a precision of 2.7 l min(-1). The correlation between CCO(PAC) and cardiac output measured by transcardiopulmonary thermodilution was also significant (r (2) = 0.781, p < 0.0001). There was a bias for the two methods of 0.2 l min(-1), and a precision of 2.2 lmin(-1). The GEDV showed no correlation with central venous pressure, pulmonary artery occlusion pressure, or RVEDV. CONCLUSION: In patients with septic shock, the averaged bias in continuous measurement of cardiac output by both a modified pulmonary artery catheter and pulse-contour analysis was small, but variability was large. No correlation was found between GEDV and RVEDV. The clinical importance of different cardiac filling parameters needs further investigation.

Thrombolytics in CPR. Current advantages in cardiopulmonary resuscitation.

Cardiac arrest carries a very poor prognosis. More than 70% of cardiac arrests are caused by acute myocardial infarction (AMI) or massive pulmonary embolism (PE). Thrombolysis during CPR has two major effects: first, it causally treats the condition that caused cardiac arrest and second, it has been shown to have beneficial effects on the microcirculatory cerebral reperfusion after cardiac arrest. However, this treatment has been widely withheld mainly because of the fear of severe bleeding complications. We reviewed the currently available in- and out-of-hospital studies on thrombolysis during CPR. Most studies found that thrombolytic therapy during CPR improves the chance for a restoration of spontaneous circulation in patients suffering from cardiac arrest and may even result in a better outcome. In addition, the neurological condition of surviving patients may be markedly improved by thrombolysis. Although thrombolytic therapy is associated with a risk of bleeding complications, currently available data do not suggest an increase of bleeding complications if thrombolysis is administered during CPR. Recently, a large randomized multicentre study has started to assess the efficacy and safety of thrombolysis during prehospital CPR.

International multicentre trial protocol to assess the efficacy and safety of tenecteplase during cardiopulmonary resuscitation in patients with out-of-hospital cardiac arrest: the Thrombolysis in Cardiac Arrest (TROICA) Study.

Prehospital cardiac arrest has been associated with a very poor prognosis. Acute myocardial infarction and massive pulmonary embolism are the underlying causes of out-of-hospital cardiac arrest in 50-70% of patients. Although fibrinolysis is an effective treatment strategy for both myocardial infarction and pulmonary embolism, clinical experience for this therapy performed during resuscitation has been limited owing to the anticipated risk of severe bleeding complications. The TROICA study is planned as one of the largest randomized, double-blind, placebo-controlled trials to assess the efficacy and safety of prehospital thrombolytic therapy in cardiac arrest of presumed cardiac origin. Approximately 1000 patients with cardiac arrest will be randomized at approximately 60 international study centres to receive either a weight-adjusted dose of tenecteplase or placebo after the first dose of a vasopressor. Patients can be included if they are at least 18 years, presenting with a witnessed cardiac arrest of presumed cardiac origin, and if either basic life support had started within 10 min of onset and had been performed up to 10 min or advanced life support is started within 10 min of onset of cardiac arrest. Primary endpoint of the study is the 30-day survival rate, and the coprimary endpoint is hospital admission. Secondary endpoints are the return of spontaneous circulation (ROSC), survival after 24 h, survival to hospital discharge, and neurological performance. Safety endpoints include major bleeding complications and symptomatic intracranial haemorrhage.

[Errors and risks in perioperative thrombolysis therapy]. / Fehler und Gefahren der perioperativen Lysetherapie.

Until recently, perioperative thrombolysis has always been thought to be a contraindication, because of the risk of bleeding complications. However, many case reports now show that thrombolytic drugs can be successfully used in the perioperative period. Possible indications for perioperative thrombolysis are massive pulmonary embolism and cardiopulmonary resuscitation which are also important causes of cardiac arrest. Thrombolysis can be the decisive therapeutical option, e.g. when normal cardiopulmonary resuscitation measures are not successful. Nevertheless, even against the background of many positive case reports the indication for perioperative thrombolysis should be a case-specific decision as the frequency of complications depends on the surgical intervention and must be weighed against the possible benefits of early thrombolysis. For perioperative thrombolysis there are no data available showing a beneficial effect of one particular therapeutic regimen. In the literature it is suggested that thrombolysis should be performed as quickly as possible, because the risk of bleeding complications depends more on the duration of thrombolysis than on the dosage or the thrombolytic drug itself.

[Prehospital thrombolysis during cardiopulmonary resuscitation]. / Prähospitale Thrombolyse während der kardiopulmonalen Reanimation.

Although prehospital cardiac arrest has an incidence of 40-90/100,000 inhabitants per year, there has been a lack of therapeutic options to improve the outcome of these patients. Of all cardiac arrests, 50-70% are caused by acute myocardial infarction (AMI) or massive pulmonary embolism (PE). Thrombolysis has been shown to be a causal and effective therapy in patients with AMI or PE who do not suffer cardiac arrest. In contrast, experience with the use of thrombolysis during cardiac arrest has been limited. Thrombolysis during cardiopulmonary resuscitation (CPR) acts directly on thrombi or emboli causing AMI or PE. In addition, experimental studies suggest that thrombolysis causes an improvement in microcirculatory reperfusion after cardiac arrest. In-hospital and prehospital case series and clinical studies suggest that thrombolysis during CPR may cause a restoration of spontaneous circulation and survival even in patients that have been resuscitated conventionally without success. In addition, there is evidence for an improved neurological outcome in patients receiving a thrombolytic therapy during during CPR. A large randomized, double-blind multicenter trial that has started recently is expected to show if this new therapeutic option can generally improve the prognosis of patients with cardiac arrest.

Thrombolytic therapy during or after cardiopulmonary resuscitation. Efficacy and safety of a new therapeutic approach.

Acute myocardial infarction (MI) and massive pulmonary embolism (PE) are the underlying causes of cardiac arrest in more than 70% of patients. Thrombolysis is an effective therapy for patients presenting with acute MI or massive PE and has experimentally shown to have beneficial effects on the microcirculatory reperfusion after cardiac arrest, but this treatment has been widely withheld up to now mainly because of the fear of severe bleeding complications. To assess the efficacy and safety of thrombolysis after and during cardiopulmonary resuscitation (CPR), we reviewed the currently available clinical studies on thrombolysis after and during CPR. From these data, there is increasing evidence that thrombolytic therapy during or shortly after CPR can contribute significantly to a restoration of spontaneous circulation in patients suffering from cardiac arrest. Although the use of thrombolytic agents is associated with a higher incidence of bleeding complications, currently available data do not suggest an increase of complications if thrombolysis is combined with CPR. Considering the poor outcome of patients suffering from cardiac arrest and the lack of effective and causal treatment options, the potential risks of thrombolysis after or during CPR probably do not outweigh the benefits of this treatment option.

Role of renal nerves and endogenous dopamine in amino acid-induced glomerular hyperfiltration.

The present study was performed to clarify whether urinary dopamine excretion (UDAV) and renal nerves are involved in the increase in glomerular filtration rate (GFR) induced by amino acid (AA) infusion. In thiopental-anesthetized rats, L-phenylalanine-free solutions of 10 AA (10%) either with (AATyr, n = 10) or without (AA0, n = 10) L-tyrosine (0.5%) were infused. Compared with baseline values, AATyr increased GFR from 0.83 +/- 0.05 to 1.00 +/- 0.04 ml.min-1.100 g-1 (P < 0.01) and UDAV almost fivefold from 5.81 +/- 0.46 to 28.1 +/- 7.4 pmol.min-1.100 g-1 (P < 0.01). In contrast, infusion of AAo increased GFR as did AATyr but did not significantly change UDAV. The DA2-receptor antagonist S(-)-sulpiride dose-dependently (0.5 to 15 micrograms.min-1.100 g-1) inhibited the GFR response to AA infusion but did not affect UDAV. In rats that had undergone chronic bilateral renal denervation (DNX), the AA-induced hyperfiltration was abolished completely, regardless of whether L-tyrosine was present. DNX did not affect basal UDAV, but the increase in UDAV in response to AATyr was attenuated compared with rats with innervated kidneys. Renal sodium excretion was increased almost twofold due to AA infusion and did not correlate with UDAV significantly. The data suggest 1) that urinary dopamine does not play a significant role in the regulation of kidney function, 2) that renal innervation is essential in the GFR response to systemic AA infusion, and 3) that a dopaminergic mechanism apart from tubular dopamine excretion is involved as well.