A systematic diagnostic and therapeutic approach for the treatment of patients after cardio-pulmonary resuscitation: a prospective evaluation of 212 patients over 5 years.

A literature on systematic treatment protocols for patients after resuscitation for cardiac arrest is lacking. We evaluated a systematic protocol, including ECG, echocardiogram, urgent cardiac catheterisation ("STEMI-like" workflow), CT scans, laboratory findings, IABP, hypothermia, and cMRI, prospectively over 5 years. The primary endpoint was the Cerebral Performance Category Scale (CPCS). During the period from January 2008 to December 2012, 212 patients were included. The mean age was 66.7 years, n = 151 (71.2 %) were male, mean time from the first medical contact to start of catheterisation was 76.6 min, and ventricular fibrillation (VF) was present in n = 99 (46.7 %). A significant coronary artery stenosis was seen in n = 130 (61.3 %), PCI was performed in n = 101 (47.6 %), an ACS was found in n = 100 (47.2 %), n = 91 patients (42.9 %) had another cardiac cause, an extra-cardiac cause was found in n = 12 (5.7 %, mostly a cerebral process), and in 9 patients (4.3 %), no cause was identifiable. A significant difference in mortality was found for patients with TIMI flow 2/3 vs. 0/1 (65.4 vs. 95.7 %, p < 0.01). The difference of intra-aortic balloon pumping vs. no pumping was not significant, performing hypothermia reduced mortality significantly (52.7 vs. 68.2 %, p = 0.04). The survival rate was n = 76 (35.9 %), a CPCS of 1/2 was reached in n = 68 pts (32.1 %), patients with ongoing resuscitation had a 100 % mortality (n = 41), and VF had a lower mortality (54.6 vs. 72.6 %, p < 0.01). A systematic algorithm may improve the outcome of patients after reanimation compared with classically reported outcomes. The data are hypothesis generating for further studies.

Rosiglitazone dampens pulmonary inflammation in a porcine model of acute lung injury.

The hallmarks of acute lung injury (ALI) are the compromised alveolar-capillary barrier and the extravasation of leukocytes into the alveolar space. Given the fact that the peroxisome proliferator-activated receptor-γ agonist rosiglitazone holds significant anti-inflammatory properties, we aimed to evaluate whether rosiglitazone could dampen these hallmarks of local pulmonary inflammation in a porcine model of lung injury. For this purpose, we used a model of lipopolysaccharide (LPS, 50 µg/kg)-induced ALI. One hundred twenty minutes following the infusion of LPS, we started the exposure to rosiglitazone through inhalation or infusion. We found that intravenous rosiglitazone significantly controlled local pulmonary inflammation as determined through the expression of cytokines within the alveolar compartment. Furthermore, we found a significant reduction of the protein concentration and neutrophil activity within the alveolar space. In summary, we therefore conclude that the treatment with rosiglitazone might dampen local pulmonary inflammation during the initial stages of ALI.

Extracorporeal cell therapy of septic shock patients with donor granulocytes: a pilot study.

INTRODUCTION: Neutrophil granulocytes are the first defense line in bacterial infections. However, granulocytes are also responsible for severe local tissue impairment. In order to use donor granulocytes, but at the same time to avoid local side effects, we developed an extracorporeal immune support system. This first-in-man study investigated whether an extracorporeal plasma treatment with a granulocyte bioreactor is tolerable in patients with septic shock. A further intention was to find suitable efficacy end-points for subsequent controlled trials. METHODS: The trial was conducted as a prospective uncontrolled clinical phase I/II study with 28-day follow-up at three university hospital intensive care units. Ten consecutive patients (five men, five women, mean age 60.3 ± 13.9 standard deviation (SD) years) with septic shock with mean ICU entrance scores of Acute Physiology and Chronic Health Evaluation (APACHE) II of 29.9 ± 7.2 and of Simplified Acute Physiology Score (SAPS) II of 66.2 ± 19.5 were treated twice within 72 hours for a mean of 342 ± 64 minutes/treatment with an extracorporeal bioreactor containing 1.41 ± 0.43 × 10E10 granulocytes from healthy donors. On average, 9.8 ± 2.3 liters separated plasma were treated by the therapeutic donor cells. Patients were followed up for 28 days. RESULTS: Tolerance and technical safety during treatment, single organ functions pre/post treatment, and hospital survival were monitored. The extracorporeal treatments were well tolerated. During the treatments, the bacterial endotoxin concentration showed significant reduction. Furthermore, noradrenaline dosage could be significantly reduced while mean arterial pressure was stable. Also, C-reactive protein, procalcitonin, and human leukocyte antigen DR (HLA-DR) showed significant improvement. Four patients died in the hospital on days 6, 9, 18 and 40. Six patients could be discharged. CONCLUSIONS: The extracorporeal treatment with donor granulocytes appeared to be well tolerated and showed promising efficacy results, encouraging further studies. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT00818597.

The neuronal guidance protein netrin-1 reduces alveolar inflammation in a porcine model of acute lung injury.

INTRODUCTION: Acute lung injury (ALI) is an inflammatory disorder of pulmonary or extrapulmonary origin. We have previously demonstrated that netrin-1 dampens murine ALI, and in an attempt to advance this finding into future clinical practice we evaluated whether netrin-1 would reduce alveolar inflammation during porcine ALI. METHODS: This was a controlled in vivo experimental study in pigs. We induced ALI through lipoploysaccharide (LPS) infusion (50 µg/kg) for 2 hours. Following this, we exposed animals to either vehicle, intravenous netrin-1 (netrin-1 i.v.) or inhaled netrin-1 (netrin-1 inh.). Serum samples and bronchoalveolar lavage (BAL) were obtained to determine levels of tumor necrosis factor-α (TNF-α), interleukin (IL)-1ß, interleukin-6 and interleukin-8 at baseline and 6 hours following treatment. Myeloperoxidase activity (MPO) and protein levels were determined in the BAL, and tissue samples were obtained for histological evaluation. Finally, animals were scanned with spiral CT. RESULTS: Following LPS infusion, animals developed acute pulmonary injury. Serum levels of TNF-α and IL-6 were significantly reduced in the netrin-1 i.v. group. BAL demonstrated significantly reduced cytokine levels 6 hours post-netrin-1 treatment (TNF-α: vehicle 633 ± 172 pg/ml, netrin-1 i.v. 84 ± 5 pg/ml, netrin-1 inh. 168 ± 74 pg/ml; both P < 0.05). MPO activity and protein content were significantly reduced in BAL samples from netrin-1-treated animals. Histological sections confirmed reduced inflammatory changes in the netrin-1-treated animals. Computed tomography corroborated reduced pulmonary damage in both netrin-1-treated groups. CONCLUSIONS: We conclude that treatment with the endogenous anti-inflammatory protein netrin-1 reduces pulmonary inflammation during the initial stages of ALI and should be pursued as a future therapeutic option.

[Controlling and operation management in hospitals]. / Controlling im Krankenhaus - Schwächen aufdecken, Potenziale ausschöpfen.

The economical pressure on the health system and especially on hospitals is growing rapidly. Hence, economical knowledge for people in medical executive positions becomes imperative. In advanced and forward-looking hospitals controlling is gaining more and more weight, because it takes over a coordinative responsibility. Ideally controlling is navigating the teamwork of managers (CEOs) and medical executives by weighing medical necessities and economical framework. Controlling is contributing to evaluate an optimal efficiency of a hospital in a highly competitive surrounding by providing medical and economical data on a regular basis. A close, open-minded and trusting cooperation between all people, who are involved, is imperative. Hence, controlling in the proper meaning of the word can not flourish in dominant and hierarchic hospital structures.

[Delivering bad news: How to improve communication with relatives]. / Psychologische Gesprächsführung - Das Uberbringen "schlechter Nachrichten" an Angehörige.

Communicating bad news, e.g. the message of the death of a close relative, is not a straight forward task for physicians. Typical common inter-speaking attitudes often fail in this difficult situation. Even simple rules and cooking recipes are seldom helpful. Medical training unfortunately does not cover this topic sufficiently. Hence physicians have to learn from trial and error. However, this trial-and-error-method may provoke an unfavourable course of conversation. Training and knowledge of evidence-based rules can improve communicative faculties and facilitate delivering bad news.

Thoracic epidural anesthesia in sepsis--is it harmful or protective?

Research interest in epidural anesthesia during sepsis has grown over the past years and studies have tried to determine its mechanisms, which should, theoretically, protect organs and reduce morbidity and mortality. However, different experimental approaches in different animal models have provided conflicting results over whether epidural anesthesia has protective or harmful effects and whether these alter depending on the phase of sepsis, the spread of epidural anesthesia or additional supportive therapies. In the future, more standardized research is necessary to integrate the results of all studies, which have been published.

Bbeta15-42 (FX06) reduces pulmonary, myocardial, liver, and small intestine damage in a pig model of hemorrhagic shock and reperfusion.

OBJECTIVE: The fibrin-derived peptide Bbeta15-42 (also called FX06) has been shown to reduce myocardial infarct size following ischemia/reperfusion. Hemorrhagic shock (HS) followed by volume resuscitation represents a similar scenario, whereby a whole organism is vulnerable to reperfusion injury. DESIGN: We subjected male farm-bred landrace pigs ( approximately 30 kg) to HS by withdrawing blood to a mean arterial pressure of 40 mm Hg for 60 minutes. Pigs were then resuscitated with shed blood and crystalloids for 60 minutes, and at this time, FX06 (2.4 mg/kg, n = 8) or vehicle control (phosphate buffered saline; 2.4 mg/kg, n = 7) was injected as an intravenous bolus. SETTING: University hospital laboratory. SUBJECTS: Anesthetized male farm-bred landrace pigs. MEASUREMENTS AND MAIN RESULTS: Data are presented as mean +/- sd. Five hours after resuscitation, controls presented acute lung injury (Pao2/Fio2-ratio <300 mm Hg; extra-vascular lung water index (marker for lung injury): 9.0 +/- 1.8 mL/kg) and myocardial dysfunction/damage (cardiac index: 4.3 +/- 0.25 L/min/m; stroke volume index: 30 +/- 6 mL/m; cardiac TnT levels: 0.58 +/- 0.25 ng/mL). In contrast, FX06-treated animals showed significantly improved pulmonary and circulatory function (Pao2/Fio2-ratio >*400 mm Hg; extra-vascular lung water index: *5.2 +/- 2.1 mL/kg, cardiac index: *6.3 +/- 1.4 L/min/m; stroke volume index: *51 +/- 11 mL/m; cardiac TnT levels: *0.11 +/- 0.09 ng/mL; *p < 0.05). Also, tissue oxygenation (tpO2; mm Hg) was significantly improved during reperfusion in FX06-treated pigs when compared with controls (liver 51 +/- 4 vs. *65 +/- 4; serosa 44 +/- 5 vs. *55 +/- 7; mucosa 14 +/- 4 vs. *26 +/- 4). Finally, FX06 reduced accumulation of myeloperoxidase-positive cells (mainly neutrophils) in myocardium, liver, and small intestine and reduced interleukin-6 plasma levels (*p < 0.05; compared with controls). CONCLUSION: We conclude that in a pig model of HS and reperfusion, administration of FX06 during reperfusion protects shock- susceptible organs such as heart, lung, liver, and small intestine.

[Central venous cannulation--the important things, you should know!]. / Der zentrale Venenkatheter--eine Literaturanalyse--Indikationen, Nutzen und Risiken.

Central venous cannulation is essential for management of patients who are critically ill or require major surgery. Based on approximately 90 studies, the use and maintainance of catheters, typical complications, most common puncture sites and techniques were sighted to give an overview over the state-of-the-art concerning central venous catheters.

[Persistent intractable hiccup in the perioperative period]. / Kasuistik--Unstillbarer Schluckauf beim Patienten in der perioperativen Phase.

We describe a case of hiccup in an awakening patient. Since there was no success in stopping the hiccup by deepening anaesthesia with Desflurane, we used Propofol 1.3 mg/kg BW as a short acting i.v. anaesthetic with a fast onset to provide early recovery after eliminating hiccup in the awakening patient. Recommendations for the therapy of hiccup range from breathing exercises to the implantation of a phrenic nerve stimulator. The small number of comparable patients and the lack of controlled studies prevent evidence-based recommendations for therapy. Currently patients profit mostly from the exchange of personal experiences.

[Brain death in children--how to deal with the parents?]. / Hirntod bei Kindern--Wie gehe ich mit den Eltern um?

For parents the death of children is hard to bear and to accept. In situations where a brain death needs to be diagnosed, the psychological stress for parents who lose their child is aggravated due to a mostly sudden and unprepared confrontation with this situation. The rationality to accept the death of a their child is opposed by the hope for recovery as long as the children are "warm and dead" instead of "cold and dead" due to the maintenance of cardiac circulation. In Germany in this situation, after diagnosing the brain death, doctors are forced by legislation to ask the parents to agree for organ donation. However, to our knowledge, no literature is available how doctors should conduct such an important conversation to the parents. This manuscript tries to give some hints for conducting a conversation from the psychological background of mourning and from our own experience gained during the last 5 years.

[Quality management in health care - continuous improvement of processes and outcomes]. / Qualitätsmanagement im Krankenhaus - Prozesse und Ergebnisse kontinuierlich verbessern.

What is quality, what is quality management? Who is responsible for quality management in a hospital? Which tools, communication instruments and which instruments for feed back are necessary for institutions to control its tasks in a multi-disciplinary environment? Are there various requirements concerning quality management systems in different hospitals or departments? Which tools of quality management are used in German anaesthesia and intensive care departments? This paper gives an introduction to quality management systems in hospitals and an overview of current models in anaesthesia and intensive care medicine.

[How to calculate the budget of an anaesthetic or intensive care department from revenues of g-DRGs]. / Krankenhausmanagement--Von InEK-Daten zum DRG-Budget.

In Germany the economical framework of the health system in general and the hospitals in particular has changed dramatically over the last years. The conversion of funding to DRGs has implicated a reduction of budgets. The apportioning of budgets by keys of officially calculating hospitals forces single departments and disciplines to choose financial goals of a hospital as their particular interest and not the financial goals of a department. The calculation of a budget for a department of anaesthesia and/or intensive care medicine is possible from fractions of all DRGs, that have been generated inside a hospital within a period of one year. However, this calculation comprises some problems, because anaesthesia and intensive care medicine are interdisciplinary disciplines, which cannot influence its achievements and its processes solely by its own, but are dependent on efficiency and quality of its partners. Internal cost allocation for improving processes seems not to be sensible in the system of DRGs as long as it is used not only as an instrument of controlling, but also as an instrument of benchmarking.

[Marketing for hospitals--an issue?]. / Marketing im Krankenhaus--(K)ein Thema?

Since economization of medicine continues, marketing is becoming more and more important. To shape marketing activities in correspondence with their professional ethics, physicians need some basic knowledge about marketing. The process of marketing consists of SWOT-analysis, market segmentation, market differentiation, positioning and the marketing-mix with ist most important component, the marketing communication. Specific aspects in the marketing of medical services derive from their nature as a service and the determinants of perceived service quality.

The impact of intra-aortic balloon pumping on cardiac output determination by pulmonary arterial and transpulmonary thermodilution in pigs.

OBJECTIVE: The aim of this study was to evaluate the impact of intra-aortic balloon pumping (IABP) on the comparison of simultaneous measurements of cardiac output via pulmonary arterial and transpulmonary thermodilution (PiCCO; Pulsion Medical Systems, Munich, Germany). DESIGN: Prospective. SETTINGS: University research laboratory. PARTICIPANTS: The data were derived from 9 anesthetized (fentanyl, propofol, flunitrazepam, rocuronium) and ventilated pigs. INTERVENTIONS: A thermodilution catheter was inserted into the pulmonary artery, a PiCCO catheter into the abdominal aorta through the right femoral artery, epicardial atrial pacing wires through a thoracotomy, and a balloon catheter for counterpulsation into the descending thoracic aorta through the left femoral artery. Cardiac output was varied over a wide range by cardiac pacing between 80 and 150/min in steps of 10/min and was measured without and during IABP at an assist frequency of 1:1. MEASUREMENTS AND MAIN RESULTS: A total of 236 paired cardiac output measurements were carried out in a range of cardiac output between 1.4 to 4.9 L/min. A close correlation was found between transpulmonary and pulmonary arterial thermodilution both without and during IABP (r = 0.94 and 0.93, respectively) and a good agreement of both methods (bias of 0.30 and 0.26 L/min, respectively; precision 0.47 and 0.52 L/min, respectively). CONCLUSIONS: Transpulmonary thermodilution is suitable for cardiac output measurement during IABP. Hence, in critically ill patients with cardiac pump failure, blood flow may be determined as accurately with the less-invasive transpulmonary method as with the traditional pulmonary arterial thermodilution one.

The effects of thoracic epidural anesthesia on hepatic perfusion and oxygenation in healthy pigs during general anesthesia and surgical stress.

Perioperative liver injury due to decreased perfusion may be an underlying mechanism behind the development of systemic inflammatory response syndrome. We designed this animal study to assess whether thoracic epidural anesthesia (TEA) impairs liver oxygenation due to induced hypotension. After ethical approval, 19 anesthetized and acutely instrumented pigs were randomly assigned to 3 groups (control and TEA alone versus TEA plus volume loading). Bupivacaine 0.5% 0.75 mL per segment was injected into the epidural space, aiming for a T5 to T12 block. After baseline values were obtained, measurements were repeated 60 and 120 min after epidural injection. TEA was associated with decreased mean arterial blood pressure but no change in total hepatic blood flow. Oxygen delivery to the liver and oxygen uptake remained unchanged. Liver tissue oxygen partial pressure did not decrease. The plasma indocyanine green disappearance rate remained stable. Volume loading before TEA did not relevantly affect total hepatic blood flow; it even decreased oxygen supply to the liver by hemodilution. We conclude that, despite decreased mean arterial blood pressure, TEA did not affect liver oxygenation. There was no clinically relevant effect of volume loading on total hepatic perfusion.