[Extracorporeal heart and lung replacement procedures]. / Extrakorporale Herz- und Lungenersatzverfahren: "Extracorporeal membrane oxygenation", "extracorporeal life support" und "pumpless extracorporeal lung assist".

The use of extracorporeal support systems in cardiac and/or pulmonary failure is an established treatment option. Although scientific evidence is limited there is an increasing amount of data from individual studies, e.g. Conventional Ventilation or ECMO for Severe Adult Respiratory Failure (CESAR) trial 2010, suggesting that extracorporeal membrane oxygenation (ECMO) as a veno-venous pump-driven system is a life-saving procedure in severe respiratory failure. Initially established as a rescue option for postcardiotomy cardiac failure extracorporeal life support (ECLS) as a pump-driven veno-arterial cardiovascular support system is increasingly being used in cardiogenic shock after myocardial infarction, as bridging to transplantation or as part of extended cardiopulmonary resuscitation. The pumpless extracorporeal lung assist (pECLA) as an arterio-venous pumpless system is technically easier to handle but only ensures sufficient decarboxylation and not oxygenation. Therefore, this method is mainly applied in primarily hypercapnic respiratory failure to allow lung protective ventilation. Enormous technical improvements, e.g. extreme miniaturization of the extracorporeal assist devices must not obscure the fact that this therapeutic option represents an invasive procedure frequently associated with major complications. With this in mind a widespread use of this technology cannot be recommended and the use of extracorporeal systems should be restricted to centers with high levels of expertise and experience.

[Perioperative antocoagulation in patients with prosthetic heart valves: recommendations]. / Perioperatives Gerinnungsmanagement bei Patienten mit Kunstklappen : Empfehlungen.

Lifelong anticoagulation, mainly with oral Vitamin K antagonists, represents the treatment of choice in patients with prosthetic heart valves to prevent thrombembolic complications. As a result, anticoagulant-related complications like excessive bleeding during interventions or surgical procedures will occur. Therefore, timely stopping of vitamin K antagonists prior to elective surgery is mandatory. However, based on the long half-life of all common vitamin K antagonists, interruption of oral anticoagulation will definitively lead to an increase of thrombembolic events. Hence, adequate bridging anticoagulation by temporary substitution of this therapy with heparin is necessary. This article gives a recommendation on the basis of the American College of Chest Physician and European Society of Cardiology current.

Prevention, diagnosis, therapy and follow-up care of sepsis: 1st revision of S-2k guidelines of the German Sepsis Society (Deutsche Sepsis-Gesellschaft e.V. (DSG)) and the German Interdisciplinary Association of Intensive Care and Emergency Medicine (Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin (DIVI)).

Practice guidelines are systematically developed statements and recommendations that assist the physicians and patients in making decisions about appropriate health care measures for specific clinical circumstances taking into account specific national health care structures. The 1(st) revision of the S-2k guideline of the German Sepsis Society in collaboration with 17 German medical scientific societies and one self-help group provides state-of-the-art information (results of controlled clinical trials and expert knowledge) on the effective and appropriate medical care (prevention, diagnosis, therapy and follow-up care) of critically ill patients with severe sepsis or septic shock. The guideline had been developed according to the "German Instrument for Methodological Guideline Appraisal" of the Association of the Scientific Medical Societies (AWMF). In view of the inevitable advancements in scientific knowledge and technical expertise, revisions, updates and amendments must be periodically initiated. The guideline recommendations may not be applied under all circumstances. It rests with the clinician to decide whether a certain recommendation should be adopted or not, taking into consideration the unique set of clinical facts presented in connection with each individual patient as well as the available resources.

S3 guidelines for intensive care in cardiac surgery patients: hemodynamic monitoring and cardiocirculary system.

Hemodynamic monitoring and adequate volume-therapy, as well as the treatment with positive inotropic drugs and vasopressors are the basic principles of the postoperative intensive care treatment of patient after cardiothoracic surgery. The goal of these S3 guidelines is to evaluate the recommendations in regard to evidence based medicine and to define therapy goals for monitoring and therapy. In context with the clinical situation the evaluation of the different hemodynamic parameters allows the development of a therapeutic concept and the definition of goal criteria to evaluate the effect of treatment. Up to now there are only guidelines for subareas of postoperative treatment of cardiothoracic surgical patients, like the use of a pulmonary artery catheter or the transesophageal echocardiography. The German Society for Thoracic and Cardiovascular Surgery (Deutsche Gesellschaft für Thorax-, Herz- und Gefässchirurgie, DGTHG) and the German Society for Anaesthesiology and Intensive Care Medicine (Deutsche Gesellschaft für Anästhesiologie und lntensivmedizin, DGAI) made an approach to ensure and improve the quality of the postoperative intensive care medicine after cardiothoracic surgery by the development of S3 consensus-based treatment guidelines. Goal of this guideline is to assess the available monitoring methods with regard to indication, procedures, predication, limits, contraindications and risks for use. The differentiated therapy of volume-replacement, positive inotropic support and vasoactive drugs, the therapy with vasodilatators, inodilatators and calcium sensitizers and the use of intra-aortic balloon pumps will also be addressed. The guideline has been developed following the recommendations for the development of guidelines by the Association of the Scientific Medical Societies in Germany (AWMF). The presented key messages of the guidelines were approved after two consensus meetings under the moderation of the Association of the Scientific Medical Societies in Germany (AWMF).

Psychosomatic evaluation of patients awaiting lung transplantation.

Levels of psychosocial functioning were assessed according to Transplantation Evaluation Rating Scale (TERS) in 113 patients prior to lung transplantation. The prevalence of mental disorders was 20%; in addition impaired mental status was observed in 12 (11%) patients. The most frequent diagnoses were dependence on tobacco (9%), adjustment disorders (4%), and dependence on alcohol (2%). In the clinical interview, 87 patients (77%) were assessed as eligible, 20 (18%) as risky, and 6 (5%) as high-risk candidates. The TERS total scores between the eligibility groups differed significantly (F = 19.5; df = 112; P < .001). There were no significant effects of gender and age. Significant inverse correlations were estimated between the TERS score and educational status (r = -.291; P = .002). TERS allows a standardized evaluation of lung transplant candidates with good discrimination into eligibility groups. General psychosocial adaptation is mainly based on the educational level, a factor that should be examined in psychosomatic assessments.

[Guidelines for intensive care in cardiac surgery patients: haemodynamic monitoring and cardio-circulatory treatment guidelines of the German Society for Thoracic and Cardiovascular Surgery and the German Society of Anaesthesiology and Intensive Care Medicine]. / Die intensivmedizinische Versorgung herzchirurgischer Patienten: Hämodynamisches Monitoring und Herz-Kreislauf-Therapie S3-Leitlinie der Deutschen Gesellschaft für Thorax-, Herz- und Gefässchirurgie (DGTHG) und der Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI).

Hemodynamic monitoring and adequate volume-therapy, as well as the treatment with positive inotropic drugs and vasopressors, are the basic principles of the postoperative intensive care treatment of patient after cardiothoracic surgery. The goal of these S3 guidelines is to evaluate the recommendations in regard to evidence based medicine and to define therapy goals for monitoring and therapy. In context with the clinical situation the evaluation of the different hemodynamic parameters allows the development of a therapeutic concept and the definition of goal criteria to evaluate the effect of treatment. Up to now there are only guidelines for subareas of postoperative treatment of cardiothoracic surgical patients, like the use of a pulmonary artery catheter or the transesophageal echocardiography. The German Society for Thoracic and Cardiovascular Surgery and the German Society for Anaesthesiology and Intensive Care Medicine made an approach to ensure and improve the quality of the postoperative intensive care medicine after cardiothoracic surgery by the development of S3 consensus-based treatment guidelines. Goal of this guideline is to assess available monitoring methods and their risks as well as the differentiated therapy of volume-replacement, positive inotropic support and vasoactive drugs, the therapy with vasodilators, inodilators and calcium-sensitizers and the use of intra-aortic balloon pumps. The guideline has been developed according to the recommendations for the development of guidelines by the Association of the Scientific Medical Societies in Germany (AWMF). The presented key messages of the guidelines were approved after two consensus meetings under the moderation of the Association of the Scientific Medical Societies in Germany (AWMF).

[Diagnosis and therapy of sepsis: guidelines of the German Sepsis Society Inc. and the German Interdisciplinary Society for Intensive and Emergency Medicine]. / Diagnose und therapie der sepsis: S2-Leitlinien der Deutschen Sepsis-Gesellschaft e.V. (DSG) und der Deutschen Interdisziplinären Vereinigung für Intensiv- und Notfallmedizin (DIVI).

A recent survey conducted by the publicly funded Competence Network Sepsis (SepNet) reveals that severe sepsis and/or septic shock occurs in 75,000 inhabitants (110 out of 100,000) and sepsis in 79,000 inhabitants (116 out of 100,000) in Germany annually. This illness is responsible for approximately 60,000 deaths and ranges as the third most frequent cause of death after acute myocardial infarction. Direct costs for the intensive care of patients with severe sepsis alone amount to approximately 1.77 billion euros, which means that about 30% of the budget in intensive care is used to treat severe sepsis. However, until now German guidelines for the diagnosis and therapy of severe sepsis did not exist. Therefore, the German Sepsis Society initiated the development of guidelines which are based on international recommendations by the International Sepsis Forum (ISF) and the Surviving Sepsis Campaign (SSC) and take into account the structure and organization of the German health care system. Priority was given to the following guideline topics: a) diagnosis, b) prevention, c) causative therapy, d) supportive therapy, e) adjunctive therapy. The guidelines development process was carefully planned and strictly adhered to the requirements of the Working Group of Scientific Medical Societies (AWMF).

[Diagnosis and therapy of sepsis]. / Diagnose und Therapie der Sepsis - S-2 Leitlinien der Deutschen Sepsis-Gesellschaft e.V. (DSG) und der Deutschen Interdisziplinären Vereinigung für Intensiv- und Notfallmedizin (DIVI).

A recent survey conducted by the publicly funded Competence Network Sepsis (Sep- Net) reveals that severe sepsis and/or septic shock occurs in 75,000 inhabitants (110 out of 100,000) and sepsis in 79,000 inhabitants (116 out of 100,000) in Germany annually. This illness is responsible for approx. 60,000 deaths and ranges as the third most frequent cause of death after acute myocardial infarction. Direct costs for the intensive care of patients with severe sepsis alone amount to approx. 1.77 billion euros, which means that about 30% of the budget in intensive care is used to treat severe sepsis. However, until now German guidelines for the diagnosis and therapy of severe sepsis did not exist. Therefore, the German Sepsis Society initiated the development of guidelines which are based on international recommendations by the International Sepsis Forum (ISF) and the Surviving Sepsis Campaign (SSC) and take into account the structure and organisation of the German health care system. Priority was given to the following guideline topics: a) diagnosis, b) prevention, c) causative therapy, d) supportive therapy, e) adjunctive therapy. The guidelines development process was carefully planned and strictly adhered to according to the requirements of the Working Group of Scientific Medical Societies (AWMF).

[Diagnosis and therapy of sepsis. Guidelines of the German Sepsis Society Inc. and the German Interdisciplinary Society for Intensive and Emergency Medicine]. / Diagnose und Therapie der Sepsis. S2-Leitlinien der Deutschen Sepsis-Gesellschaft e.V. (DSG) und der Deutschen Interdisziplinären Vereinigung für Intensiv- und Notfallmedizin (DIVI).

A recent survey conducted by the publicly funded Competence Network Sepsis (SepNet) reveals that severe sepsis and/or septic shock occurs in 75,000 inhabitants (110 out of 100,000) and sepsis in 79,000 inhabitants (116 out of 100,000) in Germany annually. This illness is responsible for approximately 60,000 deaths and ranges as the third most frequent cause of death after acute myocardial infarction. Direct costs for the intensive care of patients with severe sepsis alone amount to approximately 1.77 billion euros, which means that about 30% of the budget in intensive care is used to treat severe sepsis. However, until now German guidelines for the diagnosis and therapy of severe sepsis did not exist. Therefore, the German Sepsis Society initiated the development of guidelines which are based on international recommendations by the International Sepsis Forum (ISF) and the Surviving Sepsis Campaign (SSC) and take into account the structure and organization of the German health care system. Priority was given to the following guideline topics: a) diagnosis, b) prevention, c) causative therapy, d) supportive therapy, e) adjunctive therapy. The guidelines development process was carefully planned and strictly adhered to the requirements of the Working Group of Scientific Medical Societies (AWMF).

Impact of intraoperative myocardial cellular damage on early hemodynamics after off-pump versus on-pump coronary artery bypass surgery.

BACKGROUND: Due to the surgical trauma a small amount of myocardial cellular damage is inherent during coronary artery bypass grafting (CABG). The purpose of the present study was to assess the degree of myocardial cellular damage after off-pump (OPCAB) and on-pump CABG (ONCAB) as measured by cardiac troponin I (cTnI), creatine kinase (CK), its MB isoenzyme (CK-MB) and myoglobin (Myo) and to examine its impact on early hemodynamics after surgery. METHODS: Ninety-nine consecutive OPCAB patients, operated between 01/1999 and 01/2004, were enrolled in the present study and compared to 99 ONCAB patients operated during the same period of time, who were matched for baseline data and mean number of grafts per patient. Early hemodynamics, cTnI, CK/CK-MB and Myo were measured preoperatively and at 1, 6, 12, 24 and 48 hours (h) postoperatively. Perioperative inotropic support, clinical data and potoperative outcome were recorded prospectively. RESULTS: The two groups were similar concerning preoperative characteristics. The mean number of distal grafts/patient was 2.1 +/- 1.0 in OPCAB and 2.1 +/- 0.8 in ONCAB patients (mean +/- SD). There was no significant difference among the groups regarding early hemodynamics in terms of cardiac index (CI), systemic vascular resistance index (SVRI), and left ventricular stroke work index (LVSWI), and inotropic support. However, cTnI, CK/CK-MB but not Myo levels were significantly lower in OPCAB compared to ONCAB patients at 1, 6, 12, 24, 36 and 48 h postoperatively (P<0.05). CONCLUSIONS: Off-pump surgery results in equal early hemodynamics despite a significantly lower release of cTnI and CK, suggesting a reduced myocardial cell damage as compared to ONCAB surgery.

Modulation and source of procalcitonin in reduced renal function and renal replacement therapy.

Serum procalcitonin (PCT), an accurate marker of severe infection, is moderately increased in chronic kidney disease (CKD), peritoneal dialysis (PD) and haemodialysis (HD). We studied the extent of PCT elevation and factors accounting for elevated PCT in CKD and dialysis, and whether peripheral blood mononuclear cells (PBMC) contribute to increased PCT. In 37 controls, 281 CKD, 31 PD, and 65 HD patients without infection, PCT was measured and correlated with CKD stage, PD, HD, C-reactive protein (CRP), cardiovascular disease (CVD) and other clinical parameters. PCT release by PBMC from controls, advanced CKD, PD and HD patients (12 subjects each) was measured. PCT increased in parallel to the deterioration of CKD. Oliguria, advanced CKD, PD, HD, CVD and elevated CRP were independently associated with PCT elevation. PCT release from PBMC significantly increased in advanced CKD, PD and HD. PCT release from PBMC correlated closely with the corresponding serum PCT values (r=0.76, P <0.001). In the absence of infection, PCT may increase due to reduced renal elimination and increased synthesis, as due to PBMC. Furthermore, serum PCT could serve as a marker of low-grade inflammation and CVD, which substantially increase mortality in CKD and dialysis.

Procalcitonin for accurate detection of infection in haemodialysis.

BACKGROUND: Infection results in considerable morbidity and mortality in haemodialysis patients. Diagnosis of infection can be difficult because currently applied laboratory parameters may be non-specifically altered due to uraemia or haemodialysis (HD). This study investigated the diagnostic value and kinetics of serum procalcitonin (PCT), a low-molecular-weight protein, in patients receiving intermittent HD. METHODS: Sixty-eight patients receiving intermittent HD for end-stage renal disease (n=48) or acute renal failure (n=20) were prospectively studied, 47 treated with high-flux and 21 with low-flux membranes. Of 36 patients with severe infections or sepsis, 27 were treated with high-flux and nine with low-flux membranes. WBC, serum PCT and C-reactive protein (CRP) concentrations were measured immediately before HD, and PCT repeatedly during the following 48 h. RESULTS: When determined immediately before HD, PCT demonstrated a sensitivity of 89%, a specificity of 81%, and positive and negative predictive values of 84 and 87%, indicating severe infection or sepsis. These levels were higher than the respective values for CRP (89, 48, 68 and 78%) and WBC (58, 75, 71 and 59%). After 4 h of HD with high-flux membranes, PCT decreased significantly to 83+/-25% and did not return to predialysis concentrations before 48 h. This decrease in serum PCT resulted in markedly reduced sensitivity (65%) and negative predictive value (54%). In contrast, no marked change in PCT concentration occurred during or after HD with low-flux membranes. CONCLUSION: Serum PCT is an accurate indicator of severe infection and sepsis in patients receiving intermittent HD. High-flux membranes substantially decrease PCT. When utilizing high flux membranes, serum PCT concentrations should be determined prior to the start of HD.

Mediastinitis after cardiac surgery--epidemiology and current treatment.

Mediastinal infection is a feared complication observed after 0.4%-5% of cardiac operations. Even today the mortality remains as high as 20%-40%. We discuss the aetiology, mechanisms, prevention, diagnosis, and medical management. The staging system for mediastinal wound infections developed at a joint conference of German cardiac surgical centres is presented. The use of parenteral polyvalent immunoglobulins is also discussed.

A multicentre randomised placebo-controlled double-blind study on adjuvant treatment of mediastinitis with immunoglobulins (Pentaglobin) after cardiac surgery (ATMI): outline and preliminary study protocol for discussion. The ATMI Study Group.

We present the second draft of a consensus-assisted protocol on the adjuvant treatment after cardiac surgery with immunoglobulins of mediastinitis. CLINICAL PHASE: Phase III. OBJECTIVE OF THE STUDY: Placebo-controlled investigation of the clinical efficacy of Pentaglobin (Biotest, Germany) as an added treatment in patients with mediastinitis. MEDICATION: Group A, active Pentaglobin; Group B, placebo: 5% glucose solution with 1% human albumin. DOSAGE: 5 ml/kg body weight Pentaglobulin or placebo intravenously each day for 5 days. STUDY DESIGN: Prospective, placebo-controlled, double blind, randomised, multicentre. SAMPLE SIZE: n = 100; 50 patients with Pentaglobin (active), 50 patients with placebo. PRIMARY OUTCOME MEASURE: Cumulative therapeutic intervention scoring system (TISS-28) during hospital stay.

Concept of and preliminary trial protocol for adjuvant treatment of mediastinitis with immunoglobulins after cardiac surgery (ATMI): response to comments and criticism.

During the consensus-based process of protocol development external experts were invited to comment on a proposal for a trial protocol on adjuvant immunotreatment of patients with wound infection after median sternotomy (ATMI). Controversies and arguments can be divided into five main areas: 1) rationale and objectives; 2) criteria for patient selection; 3) adjuvant treatment; 4) measures of efficacy; and 5) course and timetable of the study. We present and summarise the experts comments and criticism as well as the result of the final discussion of the study group with respect to these areas.

Results of cardiac operations in five kidney transplant patients.

Because of the paucity of literature reports about cardiac operations in renal-transplant patients we performed a retrospective study encompassing all such patients operated upon in our institution in 1993 and 1994. During this time 5 renal transplant patients underwent cardiac surgical procedures between 1 and 9 years after transplantation: in 4 patients coronary artery bypass grafting (CABG) was carried out and in one patient aortic valve replacement. We analyzed pre-, peri-, and postoperative data. Late results were obtained by questionnaire from the patients' primary physicians. Short- and long-term results were excellent. Mortality was 0%. At late follow-up (8-23 months) all patients were in NYHA class II or better. Postoperatively all patients experienced a clear improvement of their cardiac symptoms. None of the transplanted kidneys deteriorated. One patient who had to undergo intermittent hemodialysis preoperatively improved so much that she did not require any dialysis postoperatively. Although the total number of patients in this study is limited we believe it can be stated that renal transplant patients can undergo cardiac operations with generally good results.

Use of phenotypic and genotypic fingerprinting methods in the strain identification of Aspergillus fumigatus.

Aspergillus fumigatus isolates (n = 6) from a lung transplant recipient, one isolate from a patient who had been on the same ward and a reference strain (NCPF 2140) were compared using three typing methods: SDS-PAGE, immunoblotting with serum from the transplant patient and random amplified polymorphic DNA (RAPD) assay. Neither the SDS-PAGE, immunoblot nor RAPD assay with single primers revealed differences between the eight isolates. Digestion of one primer product with the endonuclease EcoRI discriminated between the six patient isolates and the other two strains. The RAPD assay using pairwise combined primers showed identical patterns for the patient's strains but differentiated between the two other strains. It is concluded that any single technique may fail to detect strain differences and that a spectrum of typing methods is necessary in order to reveal or to exclude cross-infections with Aspergillus fumigatus.

Elimination of amrinone during continuous veno-venous haemofiltration after cardiac surgery.

We studied the elimination of amrinone during continuous veno-venous haemofiltration (CVVHF) in three anuric patients after cardiac surgery. The patients had developed low cardiac output followed by acute prerenal failure. Plasma amrinone levels measured by HPLC were fitted to a two-compartment model. We found significant amrinone clearance, with a mean sieving coefficient (S) of 0.44%, which correlates with the protein-unbound, pharmacologically effective fraction of amrinone. The AUC of the arterial plasma concentration-time curve was decreased by 49.8%. All pharmacokinetic parameters showed wide interindividual variation. To ensure the therapeutic effect of amrinone and to avoid toxic adverse effects monitoring of plasma amrinone levels is necessary.

[Concept for therapy of heart failure in heart surgery]. / Konzept zur Therapie der Herzinsuffizienz in der Herzchirurgie.

Perioperative deterioration of the circulatory performance of patients undergoing heart surgery ranges from transitory impairment in cardiac output by deterioration of the compensation range of the oxygen transport system to manifest circulatory failure without previous myocardial damage and the acute decompensation of pre-existing chronic heart failure. On the basis of the current state of knowledge in this field, a concept for rational staged treatment should be based on the different myocardial beta-adrenoceptor conditions related to the type and stage of the individual underlying heart disease and on adrenoceptor subtype specific properties of positive inotropic drugs. 1. The therapy of perioperative "circulatory" insufficiency after extra-corporal circulation consists of the use of drugs to adapt the performance of the oxygen transport system to increased overall oxygen demand. Simultaneous volume loading (by CVP) and positive inotropic support with dobutamine are the best means of treating this (normally transitory) dysregulation. 2. In the case of manifest severe circulatory insufficiency (low cardiac output syndrome), sepsis or acute heart failure (e.g., following acute myocardial infarction), the use of a pulmonary artery catheter for determining perioperative cardiac output and resistance is essential. In such cases, positive inotropic therapy is based on catecholamines of medium (dobutamine) to high (adrenaline) efficacy, because it can be assumed that the beta-adrenoceptor pattern will remain normal with regular functioning and regulation of the (remaining) myocardium up to the onset of acute heart failure.(ABSTRACT TRUNCATED AT 250 WORDS)