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1.
Resuscitation ; 2019 Aug 08.
Artigo em Inglês | MEDLINE | ID: mdl-31401135

RESUMO

BACKGROUND: Overall prognosis in patients with out-of-hospital cardiac arrest (OHCA) remains poor, especially when return of spontaneous circulation (ROSC) cannot be achieved at the scene. It is unclear if rapid transport to the hospital with ongoing cardiopulmonary resuscitation (CPR) improves outcome in patients with refractory OHCA (rOHCA). The aim of this study was to evaluate the effect of a novel fast track algorithm (FTA) in patients with rOHCA. METHODS: This prospective single-center study analysed outcome in rOHCA patients treated with FTA. Historical patients before FTA-implementation served as controls. rOHCA was defined as: persistent shockable rhythm after three shocks and 300 mg of amiodarone or persistent non-shockable rhythm and continuous CPR for 10 min without ROSC after exclusion of treatable arrest causes. RESULTS: 110 consecutive patients with rOHCA (mean age 56 ±â€¯14 years) were included. 40 patients (36%) were treated with FTA, 70 patients (64%) served as historical controls. Pre-hospital time was significantly shorter after FTA implementation (69 ±â€¯18 vs. 79 ±â€¯24 min, p = 0.02). Favourable neurological outcome (defined as cerebral performance categories Score 1 or 2) was significantly more frequent in FTA patients (27.5% vs. 11.4%, p = 0.038). FTA-implementation showed a trend towards improved mortality (70.0% vs. 82.9%, p = 0.151). Extracorporeal Life Support was similar between the two groups. CONCLUSION: Our study suggests that a rapid transport algorithm with ongoing CPR is feasible, improves neurological outcome and may improve survival in carefully selected patients with rOHCA.

3.
Artigo em Alemão | MEDLINE | ID: mdl-31278437

RESUMO

The proportion of elderly, frail, and multimorbid people has increased dramatically in recent decades resulting from demographic changes and will further increase, which will impact acute medical care. Prospective, randomized studies on geriatric intensive care are still lacking. There are also no international or national recommendations regarding the management of critically ill elderly patients. Based on an expert opinion, this consensus paper provides 16 statements that should be considered when dealing with geriatric critical care patients.

4.
Z Gerontol Geriatr ; 52(5): 440-456, 2019 Aug.
Artigo em Alemão | MEDLINE | ID: mdl-31278486

RESUMO

The proportion of elderly, frail, and multimorbid people has increased dramatically in recent decades resulting from demographic changes and will further increase, which will impact acute medical care. Prospective, randomized studies on geriatric intensive care are still lacking. There are also no international or national recommendations regarding the management of critically ill elderly patients. Based on an expert opinion, this consensus paper provides 16 statements that should be considered when dealing with geriatric critical care patients.

5.
J Am Heart Assoc ; 8(15): e010881, 2019 Aug 06.
Artigo em Inglês | MEDLINE | ID: mdl-31311438

RESUMO

Background Clinical characteristics and outcomes of takotsubo syndrome (TTS) patients with malignancy have not been fully elucidated. This study sought to explore differences in clinical characteristics and to investigate short- and long-term outcomes in TTS patients with or without malignancy. Methods and Results TTS patients were enrolled from the International Takotsubo Registry. The TTS cohort was divided into patients with and without malignancy to investigate differences in clinical characteristics and to assess short- and long-term mortality. A subanalysis was performed comparing long-term mortality between a subset of TTS patients with or without malignancy and acute coronary syndrome (ACS) patients with or without malignancy. Malignancy was observed in 16.6% of 1604 TTS patients. Patients with malignancy were older and more likely to have physical triggers, but less likely to have emotional triggers compared with those without malignancy. Long-term mortality was higher in patients with malignancy (P<0.001), while short-term outcome was comparable (P=0.17). In a subanalysis, long-term mortality was comparable between TTS patients with malignancies and ACS patients with malignancies (P=0.13). Malignancy emerged as an independent predictor of long-term mortality. Conclusions A substantial number of TTS patients show an association with malignancy. History of malignancy might increase the risk for TTS, and therefore, appropriate screening for malignancy should be considered in these patients. Clinical Trial Registration URL: http://www.clinicaltrial.gov. Unique identifier: NCT01947621.

6.
Dtsch Med Wochenschr ; 144(13): 884-891, 2019 Jul.
Artigo em Alemão | MEDLINE | ID: mdl-31252442

RESUMO

Diagnosing and managing patients in shock is a challenge for the treating clinicians in acute medicine. Early diagnosis and treatment are crucial. Mortality of septic shock is between 40 % and 60 %, and that of the cardiogenic shock about 40 %. This article provides an overview of diagnostic approaches to the patient in shock, different aetiologies and treatment strategies, and it guides the clinician through the management from first contact until definite treatment.

7.
Eur Heart J ; 40(26): 2142-2151, 2019 07 01.
Artigo em Inglês | MEDLINE | ID: mdl-31098611

RESUMO

AIMS: We aimed to evaluate the frequency, clinical features, and prognostic implications of cardiac arrest (CA) in takotsubo syndrome (TTS). METHODS AND RESULTS: We reviewed the records of patients with CA and known heart rhythm from the International Takotsubo Registry. The main outcomes were 60-day and 5-year mortality. In addition, predictors of mortality and predictors of CA during the acute TTS phase were assessed. Of 2098 patients, 103 patients with CA and known heart rhythm during CA were included. Compared with patients without CA, CA patients were more likely to be younger, male, and have apical TTS, atrial fibrillation (AF), neurologic comorbidities, physical triggers, and longer corrected QT-interval and lower left ventricular ejection fraction on admission. In all, 57.1% of patients with CA at admission had ventricular fibrillation/tachycardia, while 73.7% of patients with CA in the acute phase had asystole/pulseless electrical activity. Patients with CA showed higher 60-day (40.3% vs. 4.0%, P < 0.001) and 5-year mortality (68.9% vs. 16.7%, P < 0.001) than patients without CA. T-wave inversion and intracranial haemorrhage were independently associated with higher 60-day mortality after CA, whereas female gender was associated with lower 60-day mortality. In the acute phase, CA occurred less frequently in females and more frequently in patients with AF, ST-segment elevation, and higher C-reactive protein on admission. CONCLUSIONS: Cardiac arrest is relatively frequent in TTS and is associated with higher short- and long-term mortality. Clinical and electrocardiographic parameters independently predicted mortality after CA.

9.
PLoS One ; 14(3): e0213261, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30856204

RESUMO

BACKGROUND: Psychological distress is common in patients with cardiovascular disease and negatively impacts outcome. HYPOTHESIS: Psychological distress is high in acute high risk cardiac patients eligible for a WCD, and associated with low quality of life. Distress is aggravated by WCD. METHODS: Consecutive patients eligible for a WCD were included in the prospective, multicenter "Cologne Registry of External Defibrillator" registry. Quality of life (Short Form-12), depressive symptoms (Beck-Depression Inventory II) and anxiety (State Trait Anxiety Inventory) were assessed at enrollment and 6-weeks, and associations with WCD prescription were analyzed. RESULTS: 123 patients (mean [SD] age 59 [± 14] years, 75% male) were included, 85 (69%) of whom received a WCD. At enrollment 21% showed clinically significant depressive symptoms and 52% anxiety symptoms, respectively. At 6 weeks, depressive and anxious symptoms significantly decreased to 7% and 25%, respectively. Depressive symptoms at enrollment and changes at 6 weeks showed significant associations with health-related quality of life, whereas anxious symptoms did not. There was a trend for better improvement of depression scores in patients with WCD (mean [SD] change in score points: -4.1 [6.1] vs -1.8 [3.9]; p = 0.09), whereas change of the anxiousness score was not different (-4.6 [9.5]) vs -3.7 [9.1], p = 0.68). CONCLUSION: In patients eligible for a WCD, depressive and anxiety symptoms were initially common and depressive symptoms showed a strong association with reduced health-related quality of life contributing to their clinical relevance. WCD recipients showed at least similar improvement of depression and anxiety at 6 weeks when compared to non recipients.

10.
Dtsch Med Wochenschr ; 144(5): 340-345, 2019 03.
Artigo em Alemão | MEDLINE | ID: mdl-30836406

RESUMO

The determination of the cardiac preload is still a challenge for intensive care physicians. In addition to clinical assessment, both non-invasive and invasive methods exist for evaluating fluid responsiveness. The following article demonstrates one possible approach for systematic assessment of fluid responsiveness using a practical algorithm for critical care patients.


Assuntos
Cuidados Críticos , Insuficiência Cardíaca/fisiopatologia , Contração Miocárdica/fisiologia , Edema/fisiopatologia , Hidratação , Hemodinâmica/fisiologia , Humanos
11.
Infection ; 47(4): 579-587, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30847769

RESUMO

PURPOSE: Despite developments in both imaging and microbiological techniques, the final diagnosis of IE often remains challenging. In this single-center cohort study, we aimed to identify the specific indications for request of 18F-FDG-PET/CT in clinical practice and to evaluate the diagnostic benefit of this nuclear imaging technique. METHODS: A total of 235 patients with possible (n = 43) or definite (n = 192) IE according to the revised Duke criteria were prospectively studied from July 2013 until December 2016. Echocardiography was generally used as the primary cardiac imaging technique. All patients were treated by a multidisciplinary Endocarditis Team. Diagnostics with 18F-FDG-PET/CT were undertaken on request by at least one member of the multidisciplinary team when overall diagnostics were inconclusive. RESULTS: In 20 patients, 18F-FDG-PET/CT scan was performed for additional diagnostic evaluation. Hereof, 15 patients had a history of implanted cardiac prosthetic material. In six patients with definite IE, the use of 18F-FDG-PET/CT was helpful for further clarification of the diagnosis. In one patient with possible IE, the diagnosis could be reclassified to definite IE. In addition, one case of vertebral osteomyelitis as well as upper and lower leg abscesses and knee empyema were detectable as extracardiac foci. Furthermore, 18F-FDG-PET/CT leads to a modification of the management in five patients. CONCLUSION: Our findings support the utility of 18F-FDG-PET/CT as an adjunctive diagnostic tool especially in the evaluation of prosthetic valve-/cardiac device-related IE and for the detection of extracardiac foci in some cases. However, due to remaining limitations also of this imaging technique, a multidisciplinary clinical evaluation still remains the essential basis for the diagnostic assessment.

13.
Dtsch Med Wochenschr ; 144(1): 54-60, 2019 01.
Artigo em Alemão | MEDLINE | ID: mdl-30602188

RESUMO

This article aims to provide an overview of the nature and extent, risk factors and treatment strategies of co-morbid mental disorders in the context of intensive care medicine. Depressive, anxious and posttraumatic syndromes as well as deliria are common phenomena in critical care patients, which correspond with the course and outcome of the underlying physical illness. The most important factors for the occurrence of mental comorbidity and general principles of care are described.


Assuntos
Cuidados Críticos , Estado Terminal/epidemiologia , Transtornos Mentais , Comorbidade , Humanos , Transtornos Mentais/complicações , Transtornos Mentais/epidemiologia , Fatores de Risco
14.
Dtsch Med Wochenschr ; 144(2): 109-113, 2019 01.
Artigo em Alemão | MEDLINE | ID: mdl-30674059

RESUMO

HISTORY AND CLINICAL FINDING: A 76-year-old patient suffered a non-ST-elevation myocardial infarction (NSTEMI) and was admitted to our Chest Pain Unit (CPU) for further diagnostics and therapy. EXAMINATIONS AND DIAGNOSIS: Coronary angiography revealed an occlusion of the right coronary artery and catheter intervention with stent implantation was performed. Due to a high thrombotic burden, application of tirofiban was initiated. In the following, the patient developed hemodynamic instability, hemoptysis and a substantial decrease of the platelet count. THERAPY AND COURSE: Tirofiban therapy was immediately stopped. Volume therapy led to hemodynamic stabilisationand hemoptysisdisappeared. Thrombocytes normalised after application of a platelet concentrate and prednisolone. One day later, the patient developed pulmonary hemorrhage with asphyxial cardiac arrest.Within the next few days, a renewed decrease of thrombocytes occurred. Despite normalization of thrombocytes after another transfusion, the patient died in consequence of a severe sepsis. CONCLUSIONS: Thrombocytopenia is a rare but potentially severe complication of tirofiban therapy. Therapeutic strategies include termination of the triggering medication, clarification of differential diagnoses and transfusion of platelet concentrates, if necessary.


Assuntos
Intervenção Coronária Percutânea/efeitos adversos , Complicações Pós-Operatórias/induzido quimicamente , Trombocitopenia/induzido quimicamente , Microangiopatias Trombóticas/induzido quimicamente , Tirofibana/efeitos adversos , Idoso , Evolução Fatal , Humanos , Masculino
16.
Perfusion ; 34(4): 323-329, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-30574851

RESUMO

OBJECTIVE: Outcomes and treatment costs for coronary artery disease involving the left anterior descending coronary artery (LAD) are influenced by the type of treatment, which can be either isolated minimally invasive revascularization of the LAD using the internal thoracic artery (ITA) (MIDCAB) or percutaneous coronary intervention (PCI) on the LAD. This retrospective study sought to evaluate long-term survival, freedom from re-intervention and cost analysis after MIDCAB compared to PCI on the LAD. METHODS: Between 2006 and 2012, from a total of 561 patients, 106 consecutive patients with LAD stenosis underwent a MIDCAB procedure whereas 100 patients underwent elective PCI. Urgent and emergent cases were excluded from the present study (n = 355). Detailed analysis of the outcome data was performed for both groups. A Kaplan-Meier survival estimation with up to 10-year follow-up was applied for both groups for survival analysis and freedom from re-intervention. RESULTS: There were no statistically significant differences in terms of clinically relevant baseline characteristics. The outcome in the MIDCAB group was superior regarding long-term overall survival, accounting for 100% versus 92.8% at 1 year, 98.5% versus 82.1% at 6 years and 79.6% versus 61.5% at 10 years (Log Rank (Mantel-Cox) p = 0.011) and freedom from re-intervention at 10 years (97.2% vs. 86.7%, Log Rank (Mantel-Cox) p = 0.001). Intensive care unit (ICU) stay (p = 0.020) and total hospital stay (p<0.001) were significantly longer in the MIDCAB group, which was also associated with higher in-hospital costs (10,879 € vs. 4009 €, p<0.001). CONCLUSIONS: Whereas patients undergoing MIDCAB remained longer on ICU and in hospital, causing higher costs, this procedure was associated with a significantly lower incidence of repeat revascularization and significantly lower mortality compared to PCI on the LAD.

18.
Clin Res Cardiol ; 2018 Sep 04.
Artigo em Inglês | MEDLINE | ID: mdl-30361819

RESUMO

Extracorporeal cardiopulmonary resuscitation (eCPR) may be considered as a rescue attempt for highly selected patients with refractory cardiac arrest and potentially reversible aetiology. Currently, there are no randomised, controlled studies on eCPR. Thus, prospective validated predictors of benefit and outcome are lacking. Currently, selection criteria and procedure techniques differ across hospitals and standardised algorithms are lacking. Based on expert opinion, the present consensus statement provides a first standardised treatment algorithm for eCPR.

20.
J Intensive Care ; 6: 62, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30302254

RESUMO

Background: Analgosedation is a cornerstone therapy for mechanically ventilated patients in intensive care units (ICU). To avoid inadequate sedation and its complications, monitoring of analgosedation is of great importance. The aim of this study was to investigate whether monitoring of analgosedative drug concentrations (midazolam and sufentanil) might be beneficial to optimize analgosedation and whether drug serum concentrations correlate with the results of subjective (Richmond Agitation-Sedation Scale [RASS]/Ramsay Sedation Scale) and objective (bispectral (BIS) index) monitoring procedures. Methods: Forty-nine intubated, ventilated, and analgosedated critically ill patients treated in ICU were clinically evaluated concerning the depth of sedation using RASS Score, Ramsay Score, and BIS index twice a day. Serum concentrations of midazolam and sufentanil were determined in blood samples drawn at the same time. Clinical and laboratory data were statistically analyzed for correlations using the Spearman's rank correlation coefficient rho (ρ). Results: Average age of the population was 57.8 ± 16.0 years, 61% of the patients were males. Most frequent causes for ICU treatments were sepsis (22%), pneumonia (22%), or a combination of both (25%). Serum concentrations of midazolam correlated weakly with RASS (ρ = - 0.467) and Ramsay Scores (ρ = 0.476). Serum concentrations of sufentanil correlated weakly with RASS (ρ = - 0.312) and Ramsay Scores (ρ = 0.295). Correlations between BIS index and serum concentrations of midazolam (ρ = - 0.252) and sufentanil (ρ = - 0.166) were low. Conclusion: Correlations between drug serum concentrations and clinical or neurophysiological monitoring procedures were weak. This might be due to intersubject variability, polypharmacy with drug-drug interactions, and complex metabolism, which can be altered in critically ill patients. Therapeutic drug monitoring is not beneficial to determine depth of sedation in ICU patients.

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