[Successful treatment of a geriatric COVID-19 patient with severe chest trauma : An interdisciplinary case report]. / Erfolgreiche Behandlung des schweren Thoraxtraumas einer geriatrischen COVID-19-Patientin : Ein Fallbericht von interdisziplinärer Bedeutung.

The coronavirus disease 2019 (COVID-19) has spread rapidly worldwide and leads to high morbidity and mortality. Clinical experience regarding the surgical management in COVID-19 patients is limited. We report the interdisciplinary approach in a COVID-19 patient with severe thoracic trauma and pulmonary symptoms, who was admitted to the emergency unit after blunt chest trauma with dislocated serial rib fractures and concomitant hemothorax.

Attenuation of a rocuronium-induced neuromuscular block in patients receiving prednisolone.

BACKGROUND: This study tested the influence of continuous medication (more than 4 weeks) with prednisolone on a rocuronium-induced neuromuscular block. METHODS: The time course of a rocuronium-induced neuromuscular blockade (0.3 mg/kg) was investigated in 40 patients with chronic inflammatory bowel disease undergoing elective abdominal surgery. The primary end point was the time from the start of injection of rocuronium until recovery of the TOF ratio to 0.9. Twenty patients received continuous medication with prednisolone (group A), and 20 were without glucocorticoid medication (group B). Additionally, another 20 patients without inflammatory bowel disease and without glucocorticoid medication served as control (group C). RESULTS: The onset time was prolonged in group A [253 (51.2) s] compared with group B [187 (61.3) s]. Twitch height at the onset of the block was higher in group A [16.5 (0-61)%] than that in group B [5.0 (0-33)%]. The duration to 25% twitch height was shorter in group A [12.6 (0-20.7) min] compared with group B [16.7 (0-25.3) min] and group C [16.9 (0-29.3) min]. The recovery to a train-of-four ratio of 0.9 was reduced in group A [25.7 (23-34.3) min] compared with group B [34.7 (32.7-44.2) min] and group C [36.5 (31.7-42.3) min]. CONCLUSIONS: Prednisolone treatment in patients with inflammatory bowel disease is associated with a delayed onset and a shorter duration of action of rocuronium. The presence of an inflammatory bowel disease did not influence the neuromuscular block.

Effects of haemofiltration and mannitol treatment on cardiopulmonary-bypass induced immunosuppression.

Cardiac surgery using cardiopulmonary bypass (CPB) causes a systemic inflammatory response. Additionally, an impairment of the responsiveness of peripheral blood mononuclear cells (PBMC) to further immunological stimuli has been observed. The aim of our present study was to evaluate the ability of antioxidant therapy with mannitol or haemofiltration during CPB to modulate this immunosuppression after CPB. Forty-five patients undergoing elective heart-surgery were prospectively enrolled and randomized into three groups (control, mannitol, haemofiltration). Blood samples were taken after induction of anaesthesia (T1), 20 min after CPB (T2) and 24 h post-operatively (T3). Expression density of the monocytic surface receptor CD14, HLA-DR expression and cytokine release (TNF-alpha and IL10) after lipopolysaccharide-stimulation were evaluated. At T2, the CD14(dim) cell population was maintained in both intervention groups while in the control group there was a decrease of this proinflammatory monocytic phenotype. No significant differences regarding HLA-DR expression or cytokine release could be demonstrated. This study shows that the suppression of the stimulated immune response after CPB can potentially be alleviated by mannitol or haemofiltration in an experimental in-vitro setting. In the light of data showing that this depression of the immune response might affect the post-operative course of patients, these results could have a potential clinical relevance.

[Intra-articular bupivacaine following hip joint arthroscopy. Effect on postoperative pain]. / Intraartikuläre Bupivacaingabe bei Hüftgelenkarthroskopie. Effekt auf postoperative Schmerzen.

The effect of intra-articular bupivacaine on postoperative pain following arthroscopy has been intensively studied for the knee joint but no data are currently available for the hip joint. The aim of the present prospective, randomized and double-blind study was to evaluate a possible effect of intra-articular bupivacaine on postoperative pain intensity following hip arthroscopy. A total of 26 patients were included: 13 received 20 ml of 0.25% bupivacaine through the trocar at the end of surgery and 13 patients received 20 ml of 0.9% NaCl as placebo. Postoperative pain intensity was assessed using a visual analogue scale (VAS) at 0.5 h, 4 h, 8 h, 12 h, 16 h and 20 h, at rest and during movement of the joint and on the basis of additional piritramide requirements. Furthermore, a mean VAS was calculated as the arithmetic mean of all VAS scores assessed over the whole study period. In the bupivacaine group, a significantly lower mean VAS was recorded at rest (17.5 vs 27.5, p=0.05) and during movement of the hip joint (23 vs. 46, p=0.001). The additional piritramide consumption tended to be higher in the placebo group. In conclusion, intra-articular bupivacaine following arthroscopic hip surgery reduces pain in the postoperative period mainly during movement and thus may possibly allow earlier mobilization.

Effects of hyperoncotic or hypertonic-hyperoncotic solutions on polymorphonuclear neutrophil count, elastase- and superoxide-anion production: a randomized controlled clinical trial in patients undergoing elective coronary artery bypass grafting.

BACKGROUND: Hypertonic-hyperoncotic solutions may be an effective treatment for systemic inflammatory response syndrome (SIRS). With regard to the immunomodulatory effects of these drugs, previous studies demonstrated controversial results. Therefore, the present study investigated the influence of different hyperoncotic and hypertonic-hyperoncotic solutions on polymorphonuclear neutrophil leukocyte (PMNL) count, elastase and superoxide-anion production in patients undergoing elective coronary artery bypass grafting (CABG) with cardiopulmonary bypass. METHODS: Fifty patients scheduled for elective CABG with cardiopulmonary bypass were randomly assigned to five groups: (i) NaCl 0.9%, 750 ml/m(2) body surface area (BSA); (ii) hydroxyethylic starch 10%, 250 ml/m(2) BSA and NaCl 0.9%, 400 ml/m(2) BSA; (iii) dextran 10%, 250 ml/m(2) BSA and NaCl 0.9%, 300 ml/m(2) BSA; (iv) hypertonic sodium chloride 7.2%/hyperoncotic hydroxyethylic starch 10%, 150 ml/m(2) BSA; and (v) hypertonic sodium chloride 7.2%/hyperoncotic dextran 10%, 150 ml/m(2) BSA. Blood samples were drawn from arterial, central venous and coronary artery sinus catheters peri-operatively. PMNL count, superoxide-anion production and elastase were recorded. RESULTS: PMNL counts and elastase activity increased in all groups after reperfusion. Superoxide-anion production showed only minor changes. Between groups, no significant differences were demonstrated. CONCLUSIONS: Infusion of clinically relevant doses of hypertonic-hyperoncotic solution did not affect PMNL count, elastase- or superoxide-anion production during elective CABG with cardiopulmonary bypass.

Antibiotics modulate the stimulated cytokine response to endotoxin in a human ex vivo, in vitro model.

BACKGROUND: Sepsis may lead to the suppression of stimulated cytokine release after Gram-negative stimuli, correlating with a fatal outcome. Treatment of sepsis includes adequate therapy with antibiotics. The aim of this study was to investigate the role of antibiotics in the modulation of the lipopolysaccharide (LPS)-stimulated cytokine response of human monocytes. METHODS: In this ex vivo, in vitro study, whole blood samples were taken from 10 healthy volunteers, stimulated with LPS in the presence or absence of various antibiotics (penicillin, amoxicillin, cefuroxime, ceftazidime, cefotaxime, piperacillin/tazobactam, imipenem/cilastatin, gentamicin, netilmicin, ciprofloxacin, vancomycin) and cultured for 24 h. Thereafter, tumor necrosis factor-alpha (TNF-alpha) and interleukin-10 (IL-10) were measured in the supernatants by enzyme-linked immunosorbent assay (ELISA). Furthermore, CD14 and HLA-DR expression on monocytes was assessed using flow cytometry. RESULTS: All cephalosporins decreased LPS-stimulated IL-10 release. Cefuroxime and cefotaxime also decreased the expression density of the LPS recognition molecule CD14 on monocytes. An increase in LPS-stimulated IL-10 release was observed with vancomycin. A suppression of LPS-stimulated TNF-alpha and IL-10 release was observed in the presence of ciprofloxacin. CONCLUSION: These results indicate a modulation of the expression density of CD14 on monocytes, together with a shift from a balanced to an inflammatory cytokine release pattern, by cefuroxime and cefotaxime. Vancomycin changes the response to an anti-inflammatory release pattern. After ciprofloxacin, a profound unresponsiveness of immune-competent cells to LPS stimulation is observed. Because of the critical role of a balanced innate immune response, these data may be of importance for the selection of antibiotics in septic patients.

[Myocardial preconditioning with volatile anesthetics. General anesthesia as protective intervention?]. / Myokardiale Präkonditionierung durch volatile Anästhetika. Narkose als protektive Intervention?

Reduction of the perioperative cardiovascular risk with pharmacological interventions plays a prominent role in routine anesthesia practice. For example, perioperative beta-blockade is well established in anesthesiological treatment of patients. There is a growing body of evidence supporting the cardioprotective effects of volatile anesthetics known as anesthetic-induced preconditioning. There are numerous and complex data from animal studies. The mechanisms of anesthetic-induced preconditioning have been extensively studied but have still not been clearly identified. Initial clinical data show the cardioprotective effects of volatile agents by looking at parameters of myocardial function and laboratory values and therefore, the question of the relevance of these data for routine clinical practice has been raised. This review gives a summary of the currently available data focusing on the mechanisms of anesthesiological preconditioning and clinical studies.

[Cholinesterase inhibitors. Importance in anaesthesia, intensive care medicine, emergency medicine and pain therapy]. / Cholinesterasehemmer. Stellenwert in Anästhesie, Intensivmedizin, Notfallmedizin und Schmerztherapie.

Many drugs currently used in anaesthesia practice modify cholinergic transmission, therefore, acetylcholinesterase inhibitors are a part of anaesthetic pharmacology. Besides its well established use in the antagonism of neuromuscular blockades and the therapy of central anticholinergic syndrome (CAS), results of controlled studies and case reports suggest other favourable indications such as the prevention and therapy of postanaesthetic shivering and the treatment of various types of intoxication and delirium. Cholinesterase inhibitors may also have analgesic properties. This review summarises the pharmacological and physiological background and describes favourable indications of this class of drugs.

[Gene polymorphism in intensive care patients. Is the course of disease predetermined?]. / Genpolymorphismen beim Intensivpatienten. Ist der Krankheitsverlauf vorbestimmt?

Molecular biology has revolutionized medicine by increasing our understanding of the pathophysiological mechanisms of disease and the ability to assess genetic risk. Individual differences in disease manifestation and course in intensive care medicine often cannot be explained by known phenotypic risk factors alone. Recent data suggest an association between specific genotypes and the risk of adverse clinical outcomes. This includes inflammatory responses (i.e. TNF-alpha, Il-10), infectious diseases such as pneumonia or meningitis, sepsis, ARDS, as well as the mortality of critically injured patients (polytrauma, severe brain trauma). Continued identification of such allotypes and haplotypes may not only provide insight as to why the response to treatment varies amongst individuals in the intensive care unit, but also may potentially decrease morbidity and mortality through improved risk assessment and the administration of prophylactic therapy.

[Melagatran and ximelagatran. Pharmacologic characteristics and anesthesiological aspects]. / Melagatran und Ximelagatran. Pharmakologische Eigenschaften und anästhesiologische Aspekte.

Melagatran is a direct inhibitor of thrombin and-like its oral prodrug ximelagatran-a newly developed dipetide with high antithrombotic efficacy. They present a linear dose-response, a short plasma half-life and the therapeutic range may be advantageous compared with classic anticoagulants such as heparins or vitamin K antagonists. The results of clinical studies for prevention and treatment of thromboembolic complications are encouraging. The use of melagatran and ximelagatran will gain significance in the perioperative management, thus being of particular importance for anaesthesiology and critical care medicine in the near future.