Prewarming Parturients for Cesarean Section Does Not Raise Wound Temperature But Body Heat and Level of Comfort: A Randomized Trial.

PURPOSE: Prewarming before cesarean section lowers the rates of surgical site infections (SSIs). We hypothesized that this effect is explained due to a higher core temperature resulting in a higher wound temperature. DESIGN: We conducted an open-labeled randomized study with on-term parturients scheduled for elective cesarean section under spinal anesthesia. Participants were randomized into an intervention group (prewarming) and a control group. METHODS: Core and wound temperature, comfort level, and examination results were taken at defined times until discharge from the postanesthesia care unit (PACU). There was a follow-up visit and interview 1 day after the procedure. The primary outcome was a difference in wound temperature. The secondary outcomes were differences in core temperature, patient comfort, blood loss, SSI, and neonatal outcome. FINDINGS: We randomized a total of 60 patients, 30 per group. Prewarming lead to a significantly higher core temperature. Additionally, patient comfort was significantly higher in the prewarming group even after discharge from PACU. We did not find a difference in wound temperature, SSI, neonatal outcome, or blood loss. CONCLUSIONS: Prewarming before cesarean section under spinal anesthesia maintains core temperature and improves patient comfort but does not affect wound temperature.

[Case report about an initial diagnosis of HIV-infection in a young sailor through two AIDS-defining diseases with lethal progression]. / Fallbericht über die Erstdiagnose einer HIV-Erkrankung eines jungen Seemanns durch 2 AIDS-definierende Erkrankungen mit letalem Intensivverlauf.

ANAMNESIS: We saw a previously healthy 30-year-old Southeast-Asian sailor with progredient coughing and fever. EXAMINATION: We found an atypical pneumonia along with a positive HIV-test. We performed a bronchial lavage and further diagnostics for opportunistic infections. The lab work showed a viral load of 3340 000 copies/ml and a CD4-cell-count of 36/µl. DIAGNOSIS: HIV late presenter in CDC stadium C3 with Pneumocystis jirovecii and CMV pneumonia. THERAPY: We treated with Meropenem, Moxifloxacin, Cotrimoxazol, Ganciclovir and Genvoya. CLINICAL COURSE: Due to a cardio-pulmonal deterioration invasive ventilation was necessary. In the end the patient died of multi organ failure twelve days after admission despite intensive care, hemodialysis and prone positioning. CONCLUSION: This case demonstrates the difficulties in the pharmacotherapy and with drug interactions in a HIV late presenter with multi organ failure. Consultation and advice of the hospital pharmacy and the antibiotic stewardship team was vital for treating this patient. In the end cases like the portrayed should be treated in specialized clinics.

What is the added value of CT-angiography in patients with transient ischemic attack?

BACKGROUND: Transient ischemic attack (TIA) is an important predictor for a pending stroke. Guidelines recommend a workup for TIA-patients similar to that of stroke patients, including an assessment of the extra- and intracranial arteries for vascular pathologies with direct therapeutic implications via computed tomography angiography (CTA). Aim of our study was a systematic analysis of TIA-patients receiving early CTA-imaging and to evaluate the predictive value of TIA-scores and clinical characteristics for ipsilateral vascular pathologies and the need of an invasive treatment. METHODS: We analysed clinical and imaging data from TIA patients being admitted to a tertiary university hospital between September 2015 and March 2018. Following subgroups were identified: 1) no- or low-grade vascular pathology 2) ipsilateral high-risk vascular pathology and 3) high-risk findings that needed invasive, surgical or interventional treatment. We investigated established TIA-scores (ABCD2-, the ABCD3- and the SPI-II score) and various clinical characteristics as predictive factors for ipsilateral vascular pathologies and the need for invasive treatment. RESULTS: Of 812 patients, 531 (65.4%) underwent initial CTA in the emergency department. In 121 (22.8%) patients, ipsilateral vascular pathologies were identified, of which 36 (6.7%) needed invasive treatment. The ABCD2-, ABCD3- and SPI-II-scores were not predictive for ipsilateral vascular pathologies or the need for invasive treatment. We identified male sex (OR 1.579, 95%CI 1.049-2.377, p = 0.029), a short duration of symptoms (OR 0.692, 95% CI 0.542-0.884, p = 0.003), arterial hypertension (OR 1.718, 95%CI 0.951-3.104, p = 0.073) and coronary heart disease (OR 1.916, 95%CI 1.184-3.101, p = 0.008) as predictors for ipsilateral vascular pathologies. As predictors for the need of invasive treatment, a short duration of symptoms (OR 0.565, 95%CI 0.378-0.846, p = 0.006), arterial hypertension (OR 2.612, 95%OR 0.895-7.621, p = 0.079) and hyperlipidaemia (OR 5.681, 95%CI 0.766-42.117, p = 0.089) as well as the absence of atrial fibrillation (OR 0.274, OR 0.082-0.917, p = 0.036) were identified. CONCLUSION: More than every fifth TIA-patient had relevant vascular findings revealed by acute CTA. TIA-scores were not predictive for these findings. Patients with a short duration of symptoms and a vascular risk profile including coronary heart disease, arterial hypertension and hyperlipidaemia most likely might benefit from early CTA to streamline further diagnostics and therapy.

[Lethal Heatstroke with Disseminated Intravascular Coagulopathy]. / Letaler Hitzeschock mit disseminierter intravasaler Koagulopathie.

We report on a case of severe heat stroke due to extended exposure to the sun in an enclosed glass cabin of an agricultural vehicle. Patient treatment, lab results and complications are reported and we examine the current literature on heat stroke.Heat stroke is a very rare and highly severe condition mostly suffered by vulnerable individuals or individuals exposed to extreme physical strain. Per definition a heat stroke is characterized by neurological deficit (especially loss of consciousness), and a high body temperature. Most important treatment is to lower the body temperature below 40 °C as quickly as possible. The best method is cold water immersion, but there are several other physical and invasive means that can be used. If performed within 30 minutes after the beginning of the incident this treatment decreases mortality considerably.Heat damage affects every organ and organ system. Most important are neurologic deficits, cardiovascular failure, liver failure and kidney failure. The excessive heat triggers a systemic inflammatory response syndrome (SIRS) which can lead to a disseminated intravascular coagulopathy (DIC). Haemostasis is also directly affected by the elevated temperature.Besides physical cooling, there is no known specific treatment to prevent secondary damage from heat stroke. Additionally, supportive care and ICU monitoring should be applied.