[Application and control of intravenous fluids in German intensive care units : A national survey among critical care physicians]. / Die Applikation und Steuerung von intravenösen Flüssigkeiten auf deutschen Intensivstationen : Eine nationale Umfrage unter Intensivmediziner:innen.

BACKGROUND: The administration of intravenous fluids includes various indications, e.g., fluid replacement, nutritional therapy or as a solvent for drugs and is a common routine in the intensive care unit (ICU); however, overuse of intravenous fluids can lead to fluid overload, which can be associated with a poorer outcome in critically ill patients. OBJECTIVE: The aim of this survey was to find out the current status of the use and management of intravenous fluids as well as the interprofessional cooperation involving clinical pharmacists on German ICUs. METHODS: An online survey with 33 questions was developed. The answers of 62 participants from the Scientific Working Group on Intensive Care Medicine of the German Society for Anesthesiology and Intensive Care Medicine were evaluated. RESULTS: Fluid overload occurs "frequently" in 62.9% (39/62) and "very frequently" in 9.7% (6/62) of the ICUs of respondents. An established standard for an infusion management system is unknown to 71.0% (44/62) of participants and 45.2% of the respondents stated that they did not have a patient data management system. In addition, the participants indicated how they define fluid overload. This was defined by the presence of edema by 50.9% (28/55) and by positive fluid balance by 30.9% (17/55). According to the participants septic patients (38/60; 63.3%) and cardiological/cardiac surgical patients (26/60; 43.3%) are most susceptible to the occurrence of fluid overload. Interprofessional collaboration among intensive care physicians, critical care nurses, and clinical pharmacists to optimize fluid therapy was described as "relevant" by 38.7% (24/62) and "very relevant" by 45.2% (28/62). Participants with clinical pharmacists on the wards (24/62; 38.7%) answered this question more often as "very relevant" with 62.5% (15/24). CONCLUSION: Fluid overload is a frequent and relevant problem in German intensive care units. Yet there are few established standards in this area. There is also a lack of validated diagnostic parameters and a clear definition of fluid overload. These are required to ensure appropriate and effective treatment that is tailored to the patient and adapted to the respective situation. Intravenous fluids should be considered as drugs that may exert side effects or can be overdosed with severe adverse consequences for the patients. One approach to optimize fluid therapy could be achieved by a fluid stewardship corresponding to comparable established procedures of the antibiotic stewardship. In particular, fluid stewardship will contribute to drug safety of intravenous fluids profiting from joined expertise in a setting of interprofessional collaboration. An important principle of fluid stewardship is to consider intravenous fluids in the same way as medication in terms of their importance. Furthermore, more in-depth studies are needed to investigate the effects of interprofessional fluid stewardship in a prospective and controlled manner.

[Cardiogenic shock following yew needle poisoning : Digoxin immune fab, va-ECMO and albumin dialysis for the treatment of a suicidal yew leaf poisoning]. / Kardiogener Schock nach Eibennadelintoxikation : Digitalisantidot, va-ECMO und Albumindialyse in der Therapie der suizidalen Eibennadelintoxikation.

We present the case of a 46-year-old male who developed refractory bradycardia with cardiogenic shock after attempting suicide by ingestion of yew leaves. Due to delayed availability of the Digoxin immune fab, a va-ECMO was established to maintain sufficient circulation. Administration of the digoxin fab resulted in recovery of spontaneous circulation. Continuous venovenous hemodiafiltration with hemoadsorption and albumin dialysis were initiated with the intention to remove immune fab-toxin complexes and as organ support in acute kidney and liver failure. Within 5 days the patient was successfully weaned from ECMO, liver support and renal replacement and discharged without physical sequelae.

[Preclinical management of cardiac arrest-extracorporeal cardiopulmonary resuscitation]. / Präklinisches Management bei Herz-Kreislauf-Stillstand ­ extrakorporale kardiopulmonale Reanimation.

BACKGROUND: The chances of surviving out-of-hospital cardiac arrest (OHCA) are still very low. Despite intensive efforts the outcome has remained relatively poor over many years. In specific situations, new technologies, such as extracorporeal cardiopulmonary resuscitation (eCPR) could significantly improve survival with a good neurological outcome. OBJECTIVE: Does the immediate restoration of circulation and reoxygenation via eCPR influence the survival rate after OHCA? Is eCPR the new link in the chain of survival? MATERIAL AND METHODS: Discussion of current study results and guideline recommendations. RESULTS: The overall survival rates after OHCA have remained at 10-30% over many years. Despite low case numbers more recent retrospective studies showed that an improved outcome can be achieved with eCPR. In selected patient collectives survival with a favorable neurological outcome is possible in 38% of the cases. CONCLUSION: Survival after cardiac arrest and the subsequent quality of life dependent on many different factors. The time factor, i.e. the avoidance of a no-flow phase and reduction of the low-flow phase is of fundamental importance. The immediate restoration of the circulation and oxygen supply by eCPR can significantly improve survival; however, large randomized, controlled trials are currently not available.

[Update: acute hypercapnic respiratory failure]. / Update: akute hyperkapnische respiratorische Insuffizienz.

BACKGROUND: Hypercapnic respiratory failure is a frequent problem in critical care and mainly affects patients with acute exacerbation of COPD (AECOPD) and acute respiratory distress syndrome (ARDS). In recent years, the usage of extracorporeal CO2 removal (ECCO2R) has been increasing. OBJECTIVE: Summarizing the state of the art in the management of hypercapnic respiratory failure with special regard to the role of ECCO2R. METHODS: Review based on a selective literature search and the clinical and scientific experience of the authors. RESULTS: Noninvasive ventilation (NIV) is the therapy of choice in hypercapnic respiratory failure due to AECOPD, enabling stabilization in the majority of cases and generally improving prognosis. Patients in whom NIV fails have an increased mortality. In these patients, ECCO2R may be sufficient to avoid intubation or to shorten time on invasive ventilation; however, corresponding evidence is sparse or even missing when it comes to hard endpoints. Lung-protective ventilation according to the ARDS network is the standard therapy of ARDS. In severe ARDS, low tidal volume ventilation may result in critical hypercapnia. ECCO2R facilitates compensation of respiratory acidosis even under "ultra-protective" ventilator settings. Yet, no positive prognostic effects could be demonstrated so far. CONCLUSION: Optimized use of NIV and lung-protective ventilation remains standard of care in the management of hypercapnic respiratory failure. Currently, ECCO2R has to be considered an experimental approach, which should only be provided by experienced centers or in the context of clinical trials.

[Venoarterial extracorporeal membrane oxygenation for out-of-hospital cardiac arrest. Case series of prehospital and in-hospital therapies]. / Venoarterielle extrakorporale Membranoxygenierung beim präklinischen Herz-Kreislauf-Stillstand. Fallserie prä- und innerklinischer Behandlungen.

Despite new concepts and strategies of basic and advanced life support, the outcome of patients with out-of-hospital cardiac arrest (OHCA) remains poor. The main reason accounting for these poor results is a low-flow phase during conventional cardiopulmonary resuscitation (CPR) with insufficient end organ perfusion. The early use of venoarterial extracorporeal membrane oxygenation (vaECMO) during CPR, i.e. extracorporeal resuscitation (ECPR) might improve OHCA survival rates as well as the neurological outcome in resuscitated patients. This article on a case series discusses the management of ECPR in three patients with OHCA. All patients suffered from a witnessed OHCA and received effective bystander CPR. After subsequent advanced cardiac life support could not achieve a return of spontaneous circulation (ROSC), vaECMO support was established as a bridge to therapy on site or after transportation to a primary or tertiary hospital. During the course of therapy two patients died and one patient was discharged after a full recovery. Early ECPR might improve the outcome in patients with prolonged cardiac arrest without ROSC. The use of ECPR should be based on the individual decision of an experienced ECPR team considering defined inclusion and exclusion criteria. As the outcome mainly depends on the duration and quality of conventional CPR, ECPR support should be requested immediately after establishing advanced life support (approximately 10-15 min).

[Venoarterial extracorporeal membrane oxygenation in an awake patient : Use of the mobile ECMO team for fulminant pulmonary embolism]. / Venoarterielle extrakorporale Membranoxygenierung am wachen Patienten : Einsatz des mobilen ECMO-Teams bei fulminanter Lungenarterienembolie.

The current report highlights the use of venoarterial extracorporeal membrane oxygenation (va-ECMO) in a case of pulmonary embolism complicated by right ventricular failure. A 38-year-old woman was admitted to a secondary care hospital with dyspnea and systemic hypotension. Diagnostic testing revealed a massive pulmonary embolism. Thrombolytic therapy was unsuccessful necessitating thromboendarterectomy in the presence of cardiogenic shock. To allow the necessary transport of the highly unstable patient to a tertiary care center a mobile ECMO team was called in. The team immediately initiated awake va-ECMO as a bridge to therapy. Extracorporeal support subsequently allowed a safe transportation and successful completion of the surgical procedure with complete recovery.

[Therapy of acute respiratory distress syndrome : Survey of German ARDS centers and scientific evidence]. / Therapie des akuten Lungenversagens : Umfrage an deutschen ARDS-Zentren und wissenschaftliche Evidenz.

BACKGROUND: In addition to specific treatment of the underlying cause, the therapy of acute respiratory distress syndrome (ARDS) consists of lung protective ventilation and a range of adjuvant and supportive measures. AIM: A survey was conducted to determine the current treatment strategies for ARDS in German ARDS centers. MATERIAL AND METHODS: The 39 centers listed in the German ARDS network in 2011 were asked to complete a questionnaire collecting data on the clinic, epidemiology as well as diagnostic and therapeutic measures regarding ARDS treatment. RESULTS: Of the centers 25 completed the questionnaire. In 2010 each of these centers treated an median of 31 (25-75 percentile range 20-59) patients. Diagnostic measures at admission were computed tomography of the thorax (60 % of the centers), whole body computed tomography (56 %), chest x-ray (52 %), abdominal computed tomography (32 %) and cranial computed tomography (24 %). Transesophageal echocardiography was performed in 64 %, pulmonary artery pressure was measured in 56 % and cerebral oximetry in 12 %. Sedation was regularly interrupted in 92 % of the centers and in 68 % this was attempted at least once a day. A median minimum tidal volume of 4 ml/kg (range 2-6) and a maximum tidal volume of 6 ml/kg (4-8) were used. Methods to determine the optimal positive end-expiratory pressure (PEEP) were the best PEEP method (60 %), ARDS network table (48 %), empirical (28 %), pressure volume curve (16 %), computed tomography (8 %), electrical impedance tomography (8 %) and others (8 %). Median minimum and maximum PEEPs were 10 cmH2O (range 5-15) and 21 cmH2O (15-25), respectively. Median plateau pressure was limited to 30 cmH2O (range 26-45). The respiratory rate was set below 20/min in 20 % and below 30/min in 44 %. Controlled ventilator modes were generally preferred with 80 % using biphasic positive airway pressure (BIPAP/BiLevel), 20 % pressure controlled ventilation (PCV) and 4 % airway pressure release ventilation (APRV). Assisted modes were only utilized by 8 % of the centers. Recruitment maneuvers were used by 28 %, particularly during the early phase of the ARDS. Muscle relaxants were administered by 32 % during the early phase of the ARDS. Complete prone positioning was used by 60 % of the centers, whereas 88 % utilized incomplete (135°) prone positioning. Continuous axial rotation was utilized by 16 %. Spontaneous breathing tests were used in 88 % of the centers with 60 % performing these at least once a day. Supportive therapies were frequently applied and mainly consisted of nitrous oxide (44 %), prostacycline (48 %) and corticosteroids (52 %). A restrictive fluid therapy was used in 48 % and a special nutrition regimen in 28 % of the centers. Of the participating centers 22 were able to offer extracorporeal membrane oxygenation (ECMO). In this case, respiratory therapy was modified by further reducing tidal volumes (91 %), inspiratory pressures (96 %) as well as using lower respiratory rates (≤ 8/min in 31 %). Only 9 % reduced PEEP during ECMO. Regular recruitment maneuvers were used by 14 %. Positioning maneuvers during ECMO were used by 82 %. CONCLUSIONS: Lung protective ventilation with reduced tidal volumes as well as inspiratory pressures represents the current standard of care and was utilized in all network centers. Prone positioning was widely used. Promising adjuvant therapies such as the muscle relaxation during the early phase of the ARDS, fluid restriction and corticosteroids were used less frequently. During ECMO respirator therapy was generally continued with ultraprotective ventilator settings.

[Spinal anesthesia in high-volume, low-concentration technique for Caesarean sections : Retrospective analysis]. / Spinalanästhesie zur Sectio caesarea in "High-volume-low-concentration"-Technik : Retrospektive Analyse.

BACKGROUND: Nowadays Caesarean sections are mainly undertaken using spinal anesthesia; therefore, it is important to minimize potential side effects and risks associated with this technique. Currently, many studies have been conducted to optimize the dose of local anesthetics to avoid hypotension, which often occurs during spinal anesthesia. AIM: In a retrospective study design the high-volume, low-concentration technique with up to 12 ml isobaric bupivacain 0.1% (1 mg/ml) and sufentanil (1 µg/ml), which has been used at the University Hospital Würzburg for many years was analyzed with respect to reliability and side effects. The use of this technique so far is unique among university hospitals in Germany. MATERIAL AND METHODS: Of the 1424 anesthesia protocols from 2001 to 2007 a total of 1368 were analyzed. Demographic data and parameters, such as location of puncture, dose and extent of anesthesia, hemodynamic stability and additional medication were recorded. A decrease of systolic blood pressure of more than 20% of the initial value was defined as hypotension. RESULTS: The median volume used for spinal anesthesia was 9 ml, containing 9 mg bupivacaine and 9 µg sufentanil. The rate of hypotension was 48.8 %. No significant differences in hypotension between lower and higher volumes were detectable. In 0.84% (n=12) of the cases the procedure had to be changed to general anesthesia and additional analgesia was administered in 3 cases (0.22%). CONCLUSION: The high-volume, low-concentration technique is an effective approach for spinal anesthesia with a small number of cases needing general anesthesia or additional analgesics. The rate of hypotension was moderate compared to other studies; however, because of the retrospective and non-randomized study design the dependence of this rate on dose and given volume should be interpreted with caution.

[From fishing trip to the critical care unit : Successful resuscitation after a near drowning accident]. / Vom Angelausflug auf die Intensivstation : Erfolgreiche Reanimation nach einem Ertrinkungsunfall.

BACKGROUND: In the context of the European Resuscitation Council (ERC) guidelines, modifications of the proposed treatment algorithm need to be performed in order to respond to different parameters. In this respect several factors interacting with cardiac arrest are essential and need to be included in the therapy. This case report demonstrates an example of resuscitation in the situation of hypothermia. CASE REPORT: After a near drowning accident and approximately 30 min underwater, a patient suffering from severe hypothermia initially required resuscitation after the rescue. A return of spontaneous circulation (ROSC) was successfully achieved within a short length of time and after 15 days on the intensive care unit the patient was discharged to a rehabilitation facility without any signs of focal neurological deficits. DISCUSSION: Section 8 of the ERC guidelines provides additional information for resuscitation under specific conditions. In this case report, hypothermia was one of the main criteria leading to an adjusted pharmacological therapy. Furthermore, selection of the appropriate hospital for an optimal advanced treatment including controlled warming of the patient and management of hypothermia-induced complications had to be evaluated.

[Trauma centre admission of severely injured or critically ill patients: comparison of estimated and real arrival times]. / Schockraumaufnahme schwerverletzter oder kritisch kranker Patienten: Geschätzte und tatsächliche Eintreffzeiten im Vergleich.

BACKGROUND: During early in-hospital management of the arriving trauma patient the timing of the trauma team alert is an important organisational step. To evaluate the accordance of the estimated and the real arriving time we performed a retrospective data analysis at a level I German trauma centre. METHODS: Retrospective data analysis. Trauma team alerts from September 2010 until March 2011 were analysed. According to the hospitals pre-alert algorithm, trauma team alert took place 10 min before the estimated time of arrival. RESULTS: There were 165 trauma team alerts included in the analysis. The estimated arrival time coincided with the real arrival time in less than 10 % of cases. In 76 % of the cases, the patient arrived in an acceptable time frame with the trauma team waiting less than 14 min. In 3 % of the cases, the patient arrived prior to the trauma team. CONCLUSION: An exact estimation of the arrival time is rare. With a trauma team alert 10 min prior to the estimated time of arrival, an acceptable waiting time can be achieved. Arrival of the patient prior to the trauma team can be avoided.

Combination of positioning therapy and venovenous extracorporeal membrane oxygenation in ARDS patients.

Positioning therapy may improve lung recruitment and oxygenation and is part of the standard care in severe acute respiratory distress syndrome (ARDS). Venovenous extracorporeal membrane oxygenation (vvECMO) is a rescue strategy that may ensure sufficient gas exchange in ARDS patients failing conventional therapy. The aim of this case series was to describe the feasibility and pitfalls of combining positioning therapy and vvECMO in patients with severe ARDS. A retrospective cohort of nine patients is described. The patients received 20 (15-86) hours (median, 25(th) and 75(th) percentile) of positioning therapy while being treated with vvECMO. The initial PaO2/FiO2 index was 64 (51-67) mmHg and the arterial carbon dioxide tension was 60 (50-71) mmHg. Positioning therapy included 135 degrees prone, prone positioning and continuous lateral rotational therapy. During the first three days, the oxygenation index improved from 47 (41-47) to 12 (11-14) cmH2O/mmHg. The lung compliance improved from 20 (17-28) to 42 (27-43) ml/cmH2O. Complications related to positioning therapy were facial oedema (n=9); complications related to vvECMO were entrance of air (n=1) and pump failure (n=1). However, investigation of root causes revealed no association with the positioning therapy and had no documented effect on the outcome. The reported cases suggest that positioning therapy can be performed safely in ARDS patients treated with vvECMO, providing appropriate precautions are in place and a very experienced team is present.

Influence of apneic oxygenation and minimal tidal volumes on ventilator-associated lung injury.

BACKGROUND: Protective tidal volumes such as 6 mL/kg can still result in tidal hyperinflation and expose the lung to mechanical stress. Further reduction of tidal volume and apneic oxygenation might mitigate lung injury. We aimed to assess the influence of minimal tidal volumes and apneic oxygenation in combination with arterio-venous extracorporeal lung assist (av-ECLA) on ventilator-associated lung injury. METHODS: Acute respiratory distress syndrome was induced in swine (N.=24) by saline lavage. The animals were randomized into three groups, ventilated in a pressure-controlled mode with a tidal volume (VT) of 6 mL/kg, 3 mL/kg and 0 mL/kg body weight, respectively. The latter two groups were instrumented with an av-ECLA device. Lung injury was assessed by histological examination of lung tissue at the end of the 24 hour experiment and by gas exchange parameters. RESULTS: Oxygenation was significantly lower in the 3 and 0 mL/kg groups, whereas CO2 remained in the targeted range in all groups. Histological examination revealed a reduction of tidal hyperinflation in the apical lung regions in the 3 and 0 mL/kg groups. In lower lung regions an increase of inflammation, intra-alveolar exudation and formation of atelectasis was shown in the animals ventilated with lower VTs. CONCLUSION: In combination with highly effective CO2-removal, the reduction of tidal volumes up to 0 mL was feasible. Tidal hyperinflation could be reduced in the upper lung areas, yet inflammation in the lower lung was higher with low tidal volumes. This stresses the differing mechanical properties of inhomogeneous injured lungs.

Effects of venovenous extracorporeal membrane oxygenation on cerebral oxygenation in hypercapnic ARDS.

Extracorporeal membrane oxygenation (ECMO) is increasingly used in ARDS patients with hypoxemia and/or severe hypercapnia refractory to conventional treatment strategies. However, it is associated with severe intracranial complications, e.g. ischemic or hemorrhagic stroke. The arterial carbon dioxide partial pressure (PaCO2) is one of the main determinants influencing cerebral blood flow and oxygenation. Since CO2 removal is highly effective during ECMO, reduction of CO2 may lead to alterations in cerebral perfusion. We report on the variations of cerebral oxygenation during the initiation period of ECMO treatment in a patient with hypercapnic ARDS, which may partly explain the findings of ischemic and/or hemorrhagic complications in conjunction with ECMO.

[Acute respiratory distress syndrome and septic cardiomyopathy : successful application of veno-venoarterial extracorporeal membrane oxygenation]. / Akutes Lungenversagen und septische Kardiomyopathie : Erfolgreicher Einsatz der veno-venoarteriellen extrakorporalen Membranoxygenierung.

A 30-year-old patient was admitted to hospital with fever and respiratory insufficiency due to community acquired pneumonia. Within a few days the patient developed septic cardiomyopathy and severe acute respiratory distress syndrome (ARDS) which deteriorated under conventional mechanical ventilation. Peripheral venoarterial extracorporeal membrane oxygenation (va-ECMO) was initiated by the retrieval team of an ARDS/ECMO centre at a paO2/FIO2 ratio of 73 mmHg and a left ventricular ejection fraction (EF) of 10 %. After 12 h va-ECMO was converted to veno-venoarterial ECMO (vva-ECMO) for improvement of pulmonary and systemic oxygenation. Left ventricular function improved (EF 45 %) 36 h after starting ECMO and the patient was weaned from vva-ECMO and converted to vv-ECMO. The patient was weaned successfully from vv-ECMO after 5 additional days and transferred back to the referring hospital for weaning from the ventilator.

[Obstetric analgesia in German clinics. Remifentanil as alternative to regional analgesia]. / Geburtshilfliche Analgesie in deutschen Kliniken. Remifentanil als Alternative zur Regionalanalgesie.

OBJECTIVE: Epidural regional analgesia is still recommended as the gold standard for obstetric analgesia due to its high efficacy and less depressing effects to the central nervous system. However, if absolute or relative contraindications for a regional anesthetic technique are present, there is a need for an effective and safe alternative. This survey investigates the current use of intravenous opioids, with a focus on remifentanil as patient-controlled intravenous analgesia (PCIA), in obstetrics in German hospitals. METHODS: A questionnaire was sent to 930 anesthesia units. Data were collected and analyzed using SPSS statistical package (PASW Statistics 18.0). The questionnaire requested statistics on births, the existing alternative labor analgesic techniques, intramuscular or intravenous opioids, PCIA or other options. Furthermore, the questions focused on details regarding the use of intravenous opioids in conjunction with PCIA techniques. RESULTS: Replies were received from 343 anesthetic departments (response rate 37%) and 281 clinics had an obstetric department and were included for further analysis. All clinics provided a 24 h epidural service and the most commonly used opioids were pethidine (19%), meptazinol (17%) and piritramide (16%) for intermittent intravenous/intramuscular administration. Only 0.9% of the clinics offered nitrous oxide as an alternative analgesic technique and 22 (8%) of the responding anesthetic departments offered PCIA. Remifentanil was the most popular choice in conjunction with PCIA (68%) for labor analgesia. Most hospitals offering PCIA continuously monitor oxygen saturation (91%) and the blood pressure (95%), whereas continuous electrocardiograms (18%) and clinical observation of the respiratory frequency (19%) were less commonly reported. However, most clinics offered one-to-one nursing for the parturient using an opioid PCIA. CONCLUSIONS: This survey revealed that pethidine, meptazinol and piritramide are the most common opioids for opioid-based systemic labor pain relief in Germany. If PCIA is offered, remifentanil is the most popular opioid. However, only a few clinics are routinely using PCIA for obstetric analgesia. Furthermore the study showed that the current monitoring standards seem to have room for improvement with respect to safe administration of an opioid PCIA. The safety standards require continuous observation of the oxygen saturation, the possibility for oxygen supply, one-to-one nursing for a close clinical observation of the mother and the presence of an anesthetist during the initial titration phase to safely apply this technique. Applying these safety standards PCIA may prove a useful alternative for central neuraxial labor analgesia in those women who either do not want, cannot have or do not need epidural analgesia.

[Extracorporeal membrane oxygenation and severe traumatic brain injury. Is the ECMO-therapy in traumatic lung failure and severe traumatic brain injury really contraindicated?]. / Extrakorporale Membranoxygenierung und schweres Schädel-Hirn-Trauma : Ist der ECMO-Einsatz bei polytraumatisierten ARDS-Patienten mit schwerem SHT wirklich noch kontraindiziert?

Veno-venous extracorporeal membrane oxygenation (ECMO) may be lifesaving in multiple injured patients with acute respiratory distress syndrome (ARDS) due to chest trauma. To prevent circuit thrombosis or thromboembolic complications during ECMO systemic anticoagulation is recommended. Therefore, ECMO treatment is contraindicated in patients with intracranial bleeding. The management of veno-venous ECMO without systemic anticoagulation in a patient suffering from traumatic lung failure and severe traumatic brain injury is reported.