[Severe noncardiogenic pulmonary edema due to permeability disorder after i.v. administration of CT contrast medium with subsequent venovenous extracorporeal membrane oxygenation]. / Schweres nichtkardiales Lungenödem durch Permeabilitätsstörung nach i.v.-CT-Kontrastmittel-Gabe mit konsekutiver venovenöser extrakorporaler Membranoxygenierung.

Hypersensitivity reactions are one of the most feared side effects associated with the use of CT contrast agents. Bronchospasm and lung edema are known manifestations, whereby the latter occurs much less often. In anaphylaxis, numerous mechanisms can lead to cardiac failure with subsequent lung edema. In contrast, the cardiac function is not impaired in noncardiogenic pulmonary edema (NCPE), which is a rare phenomenon but with potentially fatal outcome. The exact pathophysiology of NCPE remains unknown and characteristically response to conventional anaphylaxis treatment is poor. This article presents the case of a 48-year-old man with NCPE who underwent elective coronary CT as part of the evaluation of recurrent syncope. After administration of iodinated contrast medium the patient developed a fulminant lung edema, which led to severe hypoxemia with cardiac arrest despite immediate treatment by the medical emergency team, including assisted ventilation, prednisolone, dimetindene and adrenaline. An early echocardiographic assessment after ROSC and intubation showed an intact cardiac function and no signs of valvular pathologies. Arterial blood gas analysis revealed a severe global respiratory failure (Horowitz quotient 73), profound acidosis (pH 7.06), elevated lactate and hemoglobin levels (8.9 mmol/l and 23.7 g/dl, respectively). A chest X­ray revealed bilateral inhomogeneous opacities. Nitrous oxide was administered to improve the ventilation-perfusion mismatch. In addition, intravenous hydrocortisone was started to address the severe capillary leak syndrome. Follow-up echocardiography showed consistently stable cardiac function at all times. As the lung function deteriorated despite aggressive countermeasures, venovenous extracorporeal membrane oxygenation (ECMO) was initiated 6 h after the initial event. With the aid of ECMO support the invasiveness of mechanical ventilation could be reduced and volume substitution intensified. In the further course, microcirculatory dysfunction and respiratory function gradually improved and ECMO support could be discontinued after 70 h. The patient was extubated on day 9 and discharged to the normal ward on day 13 without any neurological impairments.

Persistence of de novo donor specific HLA-Antibodies after lung transplantation: a potential marker of decreased patient survival.

The impact of de novo donor-specific anti-HLA antibodies (DSA) on outcomes in lung transplantation is still a matter of debate. We hypothesize that differentiating DSA by persistent and transient appearance may offer an additional risk assessment. The clinical relevance of HLA-antibodies was investigated prospectively in 72 recipients with a median follow-up period of 21 months. The presence of HLA-antibodies was analysed by single antigen bead assay prior to and after (3 weeks, 3, 6, 12 and 18 months) transplantation. In 23 patients (32%) de novo DSA were detected. In 10 of these patients (44%) DSA persisted throughout the follow-up period whereas 13 of these patients (56%) had transient DSA. There was a trend towards lower one-year-survival in DSA positive compared to DSA negative patients (83% versus 94%; p=0.199). Remarkably, patients with persistent DSA had significantly reduced survival (one-year survival 60%) compared with both patients without DSA and those with transient DSA (p=0.005). Persistent DSA represented an independent prognostic factor for reduced overall survival in multivariate analysis (HR 8.3, 95% CI 1.8-37.0; p=0.006). Persistence of DSA during the first year after transplantation seems to be more harmful for lung allograft function than transiently detected DSA at an early stage. This article is protected by copyright. All rights reserved.

[Above and beyond BMI : Alternative methods of measuring body fat and muscle mass in critically ill patients and their clinical significance]. / Jenseits des BMI : Alternative Methoden zur Erfassung von Körperfett und Muskelmasse in der Intensivmedizin und deren klinischer Stellenwert.

Obesity leads to better survival in critically ill patients. Although there are several studies confirming this thesis, the "obesity paradox" is still surprising from the clinician's perspective. One explanation for the "obesity paradox" is the fact that the body mass index (BMI), which is used in almost all clinical evaluations to determine weight categories, is not an appropriate measure of fat and skeletal muscle mass and its distribution in critically ill patients. In addition, height and weight are frequently estimated rather than measured. Central obesity has been identified in many disorders as an independent risk factor for an unfavourable outcome. The first clues are to be found in intensive care. Along with obesity, an individual's entire muscle mass is a variable that has an influence on outcome. Central obesity can be measured relatively easily with an abdominal calliper, but the calculation of muscle mass is more complex. A valid and detailed measurement of this can be obtained using computed tomography (CT) images, acquired during routine care. For future clinical observation or interventional studies, single cross-sectional CT is a more sophisticated tool for measuring patients' anthropometry than a measuring tape and callipers. Patients with sarcopenic obesity, for example, who may be at a particular risk, can only be identified using imaging procedures such as single cross-sectional CT. Thus, BMI should take a back seat as an anthropometric tool, both in the clinic and in research.