[Impairment of oxygenation of patients in surgical intensive care : Early symptom of severe sepsis]. / Die Veränderung der Oxygenierung chirurgischer Intensivpatienten : Frühes Leitsymptom der schweren Sepsis.

BACKGROUND: Sepsis and septic shock are major contributors to morbidity and mortality in intensive care patients. Early identification and adequate therapy are of utmost importance to reduce the still high mortality in patients with severe sepsis. Many of the pathophysiologic changes are nonspecific. Thus, a combination of symptoms and laboratory results are necessary to confirm the diagnosis. Impairment of the Horovitz index is identified as being a primal prognostic criterion for early diagnosis in serious progression of sepsis, after exclusion of a few differential diagnoses. Based on this fact, the prevalence of this symptom compared to other sepsis parameters is of specific interest. METHOD: In a retrospective study 33 cases of serious sepsis were analysed during the patient's course of intensive care treatment focusing on oxygenation. The deterioration of oxygenation, meaning a drop in the Horovitz index below 200 mm Hg (25.7 kPa) or a decrease in paO2 by 67.5 mm Hg (9 kPa) in spontaneously breathing patients with sepsis was the mean inclusion criteria. We compared the sequence of occurrence of known sepsis markers (e. g. PCT, WBC, CRP) with the deterioration in oxygenation to answer the question whether impairment of oxygenation could be an early symptom of severe sepsis. The Mann Whitney U­test and a discriminant analysis were performed to verify differences of the variables investigated between surviving and deceased patients. Furthermore a regression analysis was performed to confirm the results of the discriminant analysis. RESULTS: The mean drop in the Horovitz index was 90 ± 24 mm Hg (12 ± 3.2 kPa) within 4.5 h respectively. This was highly significant (p < 0.001). In all patients impairment of oxygenation indicated an individual onset and further progression of a serious sepsis. In more than ¾ of all cases this symptom occurred in an earlier stage than other organ dysfunctions. In 79 % of cases, patients showed an impairment of oxygenation before PCT increased on values of >2 ng/ml. In 76 % of cases impairment of oxygenation occurred earlier than all other investigated parameters. Significant differences were found between surviving and deceased patients regarding to their age as well as the timeframe from the beginning of impaired oxygenation to the onset of the effect of the administered antibiotics. These two parameters (age, time to sufficient antibiotic therapy) were confirmed by regression analysis and showing similar effect coefficients, age 1.09 and time to sufficient antibiotic therapy 1.04 respectively. CONCLUSION: An urgent worsening of pulmonary function in patients in intensive care requires immediate differential diagnostics due to substantial therapeutic consequences. Our results confirm that impairment of pulmonary oxygenation is the first prognostic symptom of severe onset of sepsis. Consequently, we recommend that this parameter be considered in diagnostic staging. After exclusion of a few differential diagnoses impairment of oxygenation can be the very first symptom of severe sepsis. The patient's age and time to sufficient antibiotic therapy are two very important prognostic factors with respect to mortality. Early and sufficient antibiotic therapy, and in a few cases surgical intervention are of utmost importance.

Clinical presentation and blood gas analysis of multiple trauma patients for prediction of standard coagulation parameters at emergency department arrival.

OBJECTIVES: Trauma-induced coagulopathy (TIC) in multiple trauma patients is a potentially lethal complication. Whether quickly available laboratory parameters using point-of-care (POC) blood gas analysis (BGA) may serve as surrogate parameters for standard coagulation parameters is unknown. The present study evaluated TraumaRegister DGU® of the German Trauma Society for correlations between POC BGA parameters and standard coagulation parameters. METHODS: In the setting of 197 trauma centres (172 in Germany), 86,442 patients were analysed between 2005 and 2012. Of these, 40,129 (72% men) with a mean age 46 ± 21 years underwent further analysis presenting with direct admission from the scene of the accident to a trauma centre, injury severity score (ISS) ≥ 9, complete data available for the calculation of revised injury severity classification prognosis, and blood samples with valid haemoglobin (Hb) measurements taken immediately after emergency department (ED) admission. Correlations between standard coagulation parameters and POC BGA parameters (Hb, base excess [BE], lactate) were tested using Pearson's test with a two-tailed significance level of p < 0.05. A subgroup analysis including patients with ISS > 16, ISS > 25, ISS > 16 and shock at ED admission, and patients with massive transfusion was likewise carried out. RESULTS: Correlations were found between Hb and prothrombin time (r = 0.497; p < 0.01), Hb and activated partial thromboplastin time (aPTT; r = -0.414; p < 0.01), and Hb and platelet count (PLT; r = 0.301; p < 0.01). Patients presenting with ISS ≥ 16 and shock (systolic blood pressure < 90 mmHg) at ED admission (n = 4,329) revealed the strongest correlations between Hb and prothrombin time (r = 0.570; p < 0.01), Hb and aPTT (r = -0.457; p < 0.01), and Hb and PLT (r = 0.412; p < 0.01). Significant correlations were also found between BE and prothrombin time (r = -0.365; p < 0.01), and BE and aPTT (r = 0.327, p < 0.01). No correlations were found between Hb, BE and lactate lactate. CONCLUSIONS: POC BGA parameters Hb and BE of multiple trauma patients correlated with standard coagulation parameters in a large database analysis. These correlations were particularly strong in multiple trauma patients presenting with ISS > 16 and shock at ED admission. This may be relevant for hospitals with delayed availability of coagulation studies and those without viscoelastic POC devices. Future studies may determine whether clinical presentation/BGA-oriented coagulation therapy is an appropriate tool for improving outcomes after major trauma.

[Perspectives on advance directives among German intensive care physicians in leading positions]. / Umgang mit Patientenverfügungen in Deutschland.

INTRODUCTION: Six years after introduction of a law for advance directives (AD) in 2009, AD are still discussed controversially. For the first time in Germany, this study investigates intensive care physicians' perspectives on implementation of AD, and corresponding experience of ethical issues. METHODS: A standardized questionnaire was sent to German hospitals with > 300 beds and anesthesiologist-led intensive care units. The questionnaire was based on results of a previous qualitative study and was intended to be answered by one leading intensive care physician per hospital. RESULTS: N = 222/299 (74.2 % response) physicians answered the survey. Despite a number of reported problems regarding the implementation of AD, 70.6 % (n = 154/218) rated AD generally as helpful. 86.5 % (n = 185/214) would prefer a more goal-oriented approach to an intervention-oriented approach to formulate AD. Furthermore 95.9 % (n = 207/216) plead for qualified professional counseling for intensive care topics in AD. Acceptance for interventions that equal termination of treatment can be perceived. Terminal extubation in correspondence with the patient's will is done in 79.4 % (n = 173/218) of hospitals, however 54.8 % (n = 113/206) of the physicians experience terminal extubations as burdening. DISCUSSION: Supporting concepts and measures will be necessary in order to prepare valid AD and to effectively improve implementation in intensive care practice.

[Hemoglobin-oriented and coagulation factor-based algorithm : Effect on transfusion needs and standardized mortality rate in massively transfused trauma patients]. / "Hämoglobinorientierter und gerinnungsfaktorbasierter Algorithmus" : Effekt auf Transfusionsbedarf und standardisierte Mortalitätsrate bei massivtransfusionspflichtigen Traumapatienten.

BACKGROUND: Bleeding and trauma-induced coagulopathy (TIC) are major contributors to death related to trauma in the first 24 h and the major preventable contributors. Early surgical therapy and aggressive correction of TIC are key steps to prevent death in patients suffering from hemorrhage. Therefore, a standard operating procedure (SOP) using a hemoglobin (Hb)-oriented and coagulation factor-based algorithm for early correction of TIC was introduced in this level 1 trauma center. This SOP uses the correlation of the Hb values measured in the trauma bay and standard coagulation tests as the basis for various aggressive coagulation therapies. OBJECTIVE: The aim was to investigate the effectiveness of the SOP in trauma patients requiring massive transfusions. The main objective was the effect on the transfusion requirements and the standardized mortality ratio (SMR), the ratio of observed deaths to expected/predicted deaths, in the cohort of massively transfused trauma patients after introduction of the SOP compared with a historical cohort. METHOD: A retrospective, single center study was carried out at a supraregional trauma center between 2005 and 2014. After introduction of the Hb-oriented, coagulation factor-based SOP for correction of TIC in 2011 a before/after comparison of all trauma patients requiring massive transfusions during trauma bay resuscitation and intensive care unit (ICU) admission was carried out. Main outcome parameters were the transfusion requirement and the SMR. The historical cohort of massively transfused trauma patients before introduction of the SOP (group 1) was compared with the cohort after introduction of the SOP (group 2). Furthermore, the two cohorts were compared regarding injury severity, expected death calculated with the revised injury severity classification (RISC), hemostatic results on trauma bay and ICU admission, clotting therapy and outcome. RESULTS: Of the 952 patients investigated 86 (9%) required massive transfusion (45 in group 1 and 41 in group 2). Both groups were comparable regarding injury severity but showed slight differences in hemostatic results on trauma bay admission, with a trend to worse results in group 2. Differences were recorded for platelet count on trauma bay admission with significantly lower values in group 2. The RISC predicted a significant difference in the mortality rate (46.5% group 1 and 65.3% group 2) but no significant differences in the observed mortality (44.4% group 1 and 47% group 2) were recorded. The SMR decreased from 0.95 in group 1 to 0.72 in group 2, meaning that in group 1 from 21 predicated trauma deaths 20 occurred and in group 2 from 27 predicated trauma deaths 19 occurred. This difference is not statistically significant (p = 0.16) due to the small sample size but is clinically relevant. A significant reduction in the requirement of red blood cell transfusions (22.8 ± 8.1 units vs 17.6 ± 7.6 units) was achieved (p = 0.003). Significant differences between the groups were observed regarding frequency and quantity of the coagulation-promoting drugs. Compared with group 1 the SOP used in group 2 achieved significantly better hemostatic results on ICU admission for fibrinogen and Quick's value and a clear trend to better results for international normalized ratio (INR) and PTT. CONCLUSION: The SOP based on coagulation factor values and standardized clotting therapy showed a clear trend to reduction of the SMR in massively transfused trauma patients. On the other hand the SOP achieved a significant reduction in the transfusion requirements and a significant improvement in the hemostatic results in the most severely injured patients. This can be interpreted as an effective use of coagulation factors in the early hospital treatment of trauma patients with ongoing bleeding.

Predictors for postoperative nausea and vomiting after xenon-based anaesthesia.

BACKGROUND: In contrast to volatile anaesthetics, xenon acts by antagonism at N-methyl-d-aspartate receptors and antagonizes 5-hydroxytryptamine type 3 receptors that mediate nausea and vomiting. Therefore, it is unknown whether the same risk factors for postoperative nausea and vomiting (PONV) after volatile anaesthetics apply to xenon-based anaesthesia. METHODS: With ethics committee approval and written informed consent, 502 consecutive patients undergoing xenon-based anaesthesia were included in a multicentre prospective observational study. Antiemetic prophylaxis was administered at the discretion of the attending anaesthetists. Postoperative nausea and vomiting and need for antiemetic rescue medication were assessed for 24 h after anaesthesia. Multivariate logistic regression analysis was performed to quantify risk factors for PONV and need for rescue medication. RESULTS: Four hundred and eighty-eight subjects were available for the final analysis. The incidence of PONV in subjects without prophylaxis was lower than expected according to the Apfel Score (28% observed; 42% expected, P<0.001). Independent predictors for PONV were (adjusted odds ratio; 95% confidence interval) female sex (1.76; 1.08-2.89), younger patient age (0.82 per 10 yr; 0.69-0.97), and longer duration of anaesthesia (1.36 per hour; 1.17-1.59). CONCLUSIONS: The incidence of PONV was significantly lower than predicted by the Apfel Score. Female sex, younger age, and longer duration of anaesthesia are risk factors for PONV after xenon-based anaesthesia. CLINICAL TRIAL REGISTRATION: German Federal Institute for Drugs and Medical Devices number AL-PMS-01/07GER.

[Whole-body-CT in Severely Injured Children. Results of Retrospective, Multicenter Study with Patients from the TraumaRegsiter DGU®]. / Ganzkörper-CT bei schwerverletzten Kindern. Ergebnisse einer retrospektiven Multizenterstudie anhand des TraumaRegister DGU®.

BACKGROUND: A fast and comprehensive diagnostic by means of whole-body CT has been shown to reduce mortality in the adult trauma population. Therefore whole-body CT seems to be the standard in adult trauma-patients. Due to the higher radiation exposure of whole-body CT the use of this diagnostic toll in pediatric trauma patients is still under debate. It is not yet clear if whole-body CT in children can increase the probability of survival. METHOD: In a retrospective, multicenter study, we used the data recorded in the TraumaRegister DGU(®) to calculate the probability of survival according to the revised injury severity classification (RISC) and standardized mortality ratio (SMR). The SMR reflects the ratio of recorded to expected mortality. Included in the study were all children (1-15 years) and adults (16-50 years) with an Injury Severity Score (ISS)>9, who were directly admitted to the hospital from the scene of accident. We compared the groups of patients given whole-body CT or non-whole-body CT. Subgroup analysis was performed for children 1-9 years, children 10-15 years and adults. RESULTS: A total of 1,456 pediatric trauma patients (mean age 9.9 years) and 20,796 adults (mean age 32.7 years) were included in the study. In contrast to adult trauma patients, were the SMR in the whole-body CT group was significant lower; we observed no advantage for the whole-body CT in pediatric trauma patients. CONCLUSION: Due to the missing advantage of whole-body CT in the pediatric trauma population and the higher radiation exposure of whole-body CT a non-whole-body CT approach seems equivalent with a lower radiation exposure.

[Management of a 4MRGN Acinetobacter baumanii outbreak in a burn unit]. / Management eines Ausbruches mit 4 MRGN Acinetobacter baumannii in einem Brandverletzten-zentrum.

Patients with 4MRGN Acinetobacter baumanii infections in a burn unit represent great challenge. The structured management with 7 involved patients in such a situation is presented. After discovering the infectious trigger a management team is established. An immediate stop for further admissions was announced and all infected room areas and medical equipment were analysed for infection foci. The infected patients were transferred to regional hospitals or a rehabiltation hospital after finishing all surgical procedures. In one case, for whom further operations were needed, a transfer to a separated area of the intermediate care unit (IMC) within the hospital was arranged. The performed analysis of infection foci indicated a bronchoscopy tower to be the infection source. The outbreak was terminated after transferring all patients, final disinfection and subsequent nebulisation with 5-6% hydrogen peroxide within 18 days.

[Coagulation management of trauma patients with unstabile circulation : establishment of a hemoglobin-oriented standard operating procedure]. / Gerinnungsmanagement beim kreislaufinstabilen Polytraumapatienten : Erarbeitung einer hämoglobinorientierten "standard operating procedure"

INTRODUCTION: Massive hemorrhage is the leading cause of death in the first few hours following multiple trauma, therefore, early and aggressive treatment of clotting disorders and surgical intervention to stop the bleeding are of utmost importance. However, commonly performed clotting tests have a considerable latency of at least 30-45 min, whereas hemoglobin (Hb) levels can be tested very quickly. If a multiple trauma patient has already received fluid resuscitation, a certain relationship may be observed between the hemoglobin value and the development of clotting disturbances. Hence, hemoglobin may be a useful and rapidly available parameter for guiding the initial treatment of clotting disturbances in multiple trauma patients. METHODS: A Hb-guided algorithm has been developed to initiate initial clotting therapy. The algorithm contains three stages of different aggressive clotting therapy with fibrinogen, prothrombin complex concentrate (PCC), factor VIIa, tranexamic acid and desmopressin, depending on the first Hb value measured. For admission Hb levels > 5.5 mmol/l (≈8.8 g/dl) coagulation therapy is managed on the basis of the laboratory tests and if in doubt 2 g fibrinogen is administered. For admission Hb levels between 5.5 mmol/l (≈8.8 g/dl) and 4 mmol/l (≈6.5 g/dl) 2-4 g fibrinogen and 2,500-3,000 IU PCC are administered and tranexamic acid and desmopressin administration should be considered. For admission Hb levels < 4 mmol/l (≈6.5 g/dl) 4-6 g fibrinogen, 3,000-5,000 IU PCC and 1 mg factor VIIa should be administered and tranexamic acid and desmopression should be considered. All drugs mentioned should be stored in a special "coagulation box" in the hospital pharmacy and this box is brought immediately to the patient on demand. In addition to the use of clotting factors, infusions should be performed with balanced crystalloids and transfusions with an RBC/FFP ratio of 2:1-1:1. To assess the efficiency of the algorithm the routinely measured clotting parameters at trauma bay admission were compared with intensive care unit (ICU) admission and the standardized mortality ratio (SMR) was calculated. RESULTS: During a 6-month investigation period 71 severe multiple trauma patients were admitted to the trauma center and 19 patients were treated using the coagulation box of which 13 required massive transfusions. The routinely used clotting parameters markedly improved between admission to the trauma bay and ICU admission: Quick 61% versus 97% (p < 0.001), partial prothromboplastin time (PTT) 50 s versus 42 s (not significant), fibrinogen 1.7 g/l versus 2.15 g/l (not significant). Of the 19 patients 11 (58%) survived. The revised injury severity classification (RISC) predicted a survival rate of 40%, which corresponds to an SMR of 0.69, thus implying a higher survival rate than predicted. CONCLUSIONS: The Hb-driven algorithm, in combination with the coagulation box and the early use of clotting factors, may be a simple and effective tool for improving coagulopathy in multiple trauma patients.

[Methohexital for treatment of intracranial hypertension]. / Methohexital zur Therapie des erhöhten intrakraniellen Drucks.

BACKGROUND: Barbiturate coma therapy is a useful method to control increased intracranial pressure (ICP) in patients with severe brain damage if standard measures have failed to lower ICP. Pentobarbital (not available in Germany) and thiopental (in Germany only approved for induction of anesthesia) have frequently been used in patients with intracranial hypertension and the effects and side-effects are well-described. However, little is known about the effect of methohexital (the only barbiturate in Germany approved for maintaining anesthesia) in lowering increased ICP. Therefore, the effect of methohexital on ICP was studied in patients where standard measures had failed to control intracranial hypertension. METHOD: A retrospective observational study was carried out with the inclusion criteria of patient age ≥18 years and methohexital therapy for 12 h or more with ICP monitoring in place. Methohexital was administered following a standardized algorithm to patients for whom standard measures, such as deep anesthesia, normoventilation, cerebral perfusion pressure (CPP) >65 mmHg, osmotherapy, neurosurgical evacuation of mass lesions, had failed to lower ICP. Methohexital was used if the ICP had risen above 20-25 mmHg for more the 20-30 min and otherwise manageable causes for the ICP increase had been ruled out. Methohexital was given continuously in addition to standard analgesia and sedation in doses of 2-4-6 mg/kg body weight (BW), depending on the ICP lowering effect. The records of the patient data management system from the years 2008/2009 were used to compare the ICP and CPP before and during methohexital administration. For statistical analyses Student's t-test was applied for measured values and the χ(2)-test was applied for percentage values whereby p<0.05 was defined as being statistically significant. RESULTS: During the study period 36 patients required methohexital therapy and 30 fulfilled the inclusion criteria. In 26 out of 30 patients the data were complete and these 26 patients were included in the data analyses. Of the patients 6 (23%) died due to elevated intracranial hypertension and 20 patients (77%) survived. In all patients methohexital lowered the ICP from 25.2 mmHg (standard deviation, SD ±4.3 mmHg) to 19.8 mmHg (SD ±12.5 mmHg) within the first 24 h, this result closely failed to reach a level of significance. In the 20 survivors methohexital lowered the ICP from 25.88 mmHg (SD ±4.8 mmHg) to 14.25 mmHg (SD ±6.9 mmHg) within the first 24 h, which is statistically highly significant. In non-survivors the ICP had risen from 24 mmHg (SD ±2.6 mmHg) to 32 mmHg (SD ±16.3 mmHg) within the first 24 h despite all efforts. Due to the CPP driven volume and vasopressor therapy no significant changes in the CPP during methohexital administration were observed. No significant changes in brain temperature (as possible cause for the decrease of the ICP) were observed. Non-survivors received significantly more methohexital due to increased ICP and required significantly more vasopressor therapy to maintain a sufficient CPP. CONCLUSIONS: Methohexital showed a clear trend for decreasing ICP in patients with intracranial hypertension refractory to standard therapeutic measures. In survivors the effect was highly significant. Patients not responding to methohexital therapy seemed to have an unfavorable outcome.

[Different case fatality rates at German trauma centres : Critical analysis]. / Unterschiedliche Letalitätsraten an deutschen Traumazentren : Kritische Analyse.

OBJECTIVE: The level of trauma care in Germany belongs to one of the best worldwide. Nevertheless, previous studies have shown significant differences in the case fatality rates of multiple trauma patients in German trauma centres. The objective of this study was to indentify the reasons for the different outcomes based on data of the trauma registry of the German Society of Orthopaedic Surgery and Traumatology. METHODS: Due to the inadequacy of comparing only the case fataltiy rates in the different trauma centres, the data recorded in the trauma registry were analyzed in a retrospective, multicentre study to calculate the probability of survival, revised injury severity classification (RISC) and, additionally, the standardized mortality ratio (SMR) for ranking of the participating trauma centres. As a criterion for inclusion in the study, a minimum of 100 trauma patients admitted directly from the scene within a 4 year period was set. The ranking was carried out using the SMR (observed mortality divided by probability of survival). With the help of data from the trauma registry an attempt was made to find the differences in trauma management between the top 10 centres (lowest SMR), the 10 middle and the last 10 centres (highest SMR) in the ranking. RESULTS: The data of 6,522 patients were included in the study. There were significant differences in the pre-hospital time, the time spent in the emergency room (ER) and time until a CT scan had been performed. Pre-hospital time was longer in patients admitted to the top centres, whereas time in the ER was longer in the last centres of the ranking. Comparing the sum of pre-hospital time and time in the ER, there were no differences between the top and the last centres. At the scene of accident overall intubation rate and intubation rate in patients with traumatic brain injury were higher in patients admitted to the top centres. Regarding the transport modality, significantly more patients were transported by helicopter in the group of the top centres. In top centres CT scans, in particular whole-body CTs, were initiated sooner and used much more frequently so that the rate of missed injuries was much lower. The amount of fluid given at the scene of accident did not differ between the centres but the amount of fluid given in ER and the operating room until admission to the intensive care unit was significantly higher in the top centres. CONCLUSION: There are significant differences in the pre-hospital and clinical care of patients admitted to German trauma centres. Under clinical conditions a tight time management, an immediate and complete diagnostic approach, particularly by means of whole-body CT and a liberal fluid resuscitation seem to be favorable factors.

[Desmopressin (Minirin) in multiple trauma--a case report]. / Desmopressin (Minirin) beim schweren Trauma--eine Fallbeschreibung.

Bleeding and clotting disturbances are not uncommon in trauma patients and require an early and consequent therapy. Under the prevalent pathophysiological circumstances of hypothermia, acidosis and clotting disturbances, desmopressin seems to be a possible option to control diffuse bleeding. We report about 2 trauma patients with diffuse bleeding and in whom desmopressin was used successfully to control bleeding from the point of view of the authors. We discuss the advantages and disadvantages of desmopressin in the 2 patients.

[Misleading anisocoria in a comatose 15-year-old with head injury]. / Irreführende Anisokorie bei komatöser 15-Jähriger mit Kopfverletzung.

Anisocoria after blunt head trauma, associated with altered vigilance, is not unusually assumed to expanding intracranial mass lesion. Obvious signs of head-trauma and vomiting might strengthen this diagnosis. We report from an unconscious 15-year-old girl (Glasgow-Coma-Scale score 3) that showed these symptoms secondary after head-trauma due to alcohol intoxication but turned out to be misleading after cranial computed tomography (CT). Surprisingly, an artificial eye was found that previously remained undetected in clinical examination. Artificial eyes implemented after enucleation therapy in retinoblastoma or eye-trauma are nowadays perfectly fitting. Prehospital discrimination of artificial eyes and natural eyes might be difficult in comatose emergency patients. Neurological examination should check corneal reflex and manual palpation of the bulbus. Independent from anisocoria, patients presenting GCS 3 and head injury need rapid admission to CT-diagnostic, neurosurgical treatment respectively.

[Prevention of thromboembolism in German intensive care units : Results of a nationwide survey]. / Thrombembolieprophylaxe auf deutschen Intensivstationen : Ergebnisse einer bundesweiten Umfrage.

BACKGROUND: Intensive care unit (ICU) patients have a high risk of developing venous thromboembolism (VTE) and prophylaxis is recommended. Venous thromboembolism confers considerable morbidity and mortality in hospitalized patients, although few studies have focused on critically ill patients. METHOD AND OBJECTIVE: A systematic prospective mailed self-administered survey of 645 German ICU directors was performed, representing 652 ICUs throughout the country. The objective of this study was to understand current approaches to the prevention of VTE among patients in ICUs. RESULTS: Of the 652 ICUs approached, 470 (72.3%) participated. Thromboembolism prophylaxis was prescribed in 98% of the ICUs. For mechanical prophylaxis graded elastic stockings were used in 93% and pneumatic compression devices in 24%. For pharmacologic prophylaxis low molecular weight heparin was the predominant prophylactic strategy in 88%, whereas unfractionated heparin was used less often in 45%. CONCLUSION: The prescribed prophylaxis for thromboembolism in 98% of the German ICUs is surprisingly high compared to that given in the literature. A combination of mechanical and pharmacologic prophylaxis is the predominant prophylactic strategy.

New aspects in the emergency room management of critically injured patients: a multi-slice CT-oriented care algorithm.

BACKGROUND: Time-critical care of seriously injured patients is gaining more and more significance. The availability of the multi-slice CT allows a complete diagnostic assessment of injured patients in 90-240 s, but is presently carried out only at the conclusion of basic diagnostics. We investigated the effects of a clinical algorithm using multi-slice CT scanning ahead of other measures in the clinical care of seriously injured patients. METHODS: Availability of a trauma admitting room with integrated multi-slice CT scanner enabled a new algorithm for patient care. We prospectively examined the time taken to reach established benchmarks in clinical care (completion of diagnosis, completion of resuscitation, exit from the trauma room) under this new approach. Data were collected for consecutive patients with serious injury (estimated injury severity score >15), and compared to historical data from the previous 2 years. RESULTS: The new algorithm was employed in 139 patients with a mean ISS of 26.93. CT scanning was initiated 8 min (S.D. 5.7) after patient arrival, and concluded 13 min (S.D. 8.4) after patient arrival. Stabilising measures (initial resuscitation) were completed an average of 36 min from patient arrival. The length of stay in the trauma room was reduced to an average of 38 min (S.D. 19.1). Four patients required life-saving interventions after admission to the trauma room but before CT scanning began. CONCLUSIONS: A new algorithm for trauma patient care that integrates high resolution CT scanning into the early diagnostic protocol reduces the length of stay in the trauma room markedly, and will facilitate rapid therapeutic intervention in patients with unstable haemorrhagic shock or neurosurgical emergencies.

[Arterial air embolism following multiple injuries after a fall from the tenth floor]. / Arterielle Luftembolie nach Polytraumatisierung bei Sturz aus dem 10. Stock.

We report about the case of a 20-year-old patient who fell from the tenth floor. The patient suffered multiple injuries and systemic gas embolism. He survived his injuries despite CPR, massive transfusion, development of ARDS and SIRS with minimal neurological deficit. The possible pathogenesis of the systemic gas embolism as well as the therapy are discussed. Besides stabilizing the circulation with i.v. fluids, blood transfusion and catecholamine therapy, the use of hyperbaric oxygenation was the decisive therapeutic measure.

[The design of the VISEP trial. Critical appraisal]. / Studienprotokoll der VISEP-Studie. Eine kritische Stellungnahme.

The survey transcript of the VISEP interventional trial "Prospective randomized multicenter study on the influence of colloid vs crystalloid volume resuscitation and of intensive vs conventional insulin therapy on outcome in patients with severe sepsis and septic shock" [Clinical trials.gov. identifier: NCT00135473; study start April 2003] comprises, according to the data of the year 2003, methodological shortcomings which challenge a priori the study design and thus the resolution of the purpose of the study, i.e., "determination of the influence of the studied volume and insulin interventions on morbidity and mortality of patients with severe sepsis and septic shock". The most important points of criticism are: 1. A volume therapy with exclusively crystalloids or colloids with the chosen colloid hyperoncotic, hyperchloremic HES solution (10% hydroxyethyl starch: 10% Hemohes) or the crystalloid solution with high lactate content (Sterofundin) is neither acceptable nor practicable, even if only due to exceeding the maximum dosage as recommended by the manufacturer. 2. The fact known since the year 2001 that high molecular weight, poorly biodegradable HES preparations can present an independent risk-factor for acute kidney failure in patients with sepsis or septic shock was ignored: the exclusion criterion of a serum-creatinine value of >320 micromol/l (>3.6 mg/dl) was doubled in relation to the manufacturer's specification. 3. The hyperoncotic colloid solution used (10% Hemohes) may only be employed for a brief period: it is highly hyperchloremic and causes extravascular hypohydration with consecutive reduction of renal excretion, which together with HES is a fatal combination. 4. The crystalloid solution used, i.e., Sterofundin, which contains 45 mmol/l lactate, is contraindicated with septic shock as it increases the patient's O2 consumption, hinders lactate diagnostics as a hypoxia marker by simultaneous lactate infusion, and through increased gluconeogenesis leads to hyperglycemia, at least with diabetics. 5. It is doubtful whether an intensified insulin therapy (Actrapid) can be successful if insulin is administered simultaneously with iatrogenic hyperglycemia as a result of lactate influx. Due to these flaws in the design of the VISEP trial, the only consequence can be that the results of the survey are unusable, especially with regard to the point "HES and kidney function". Thus, any further advance presentations and interpretations should be shelved in expectation of the authors' publication of all the data, in order to begin further discussions including the flaws in study design listed here.

[Sudden blindness following operative care of a multiply traumatized patient: posterior ischemic optic neuropathy]. / Unerwartete Blindheit nach operativer Versorgung eines polytraumatisierten Patienten: Hintere ischämische N.-opticus-Schädigung.

A 32-year-old man had fallen from an 8-m high scaffolding and had suffered multiple traumatic injuries, such as compression fractures of the thoracic vertebrae (TV) 5-7 without incarceration of the spinal canal plus a distal femoral fracture. During surgery on the day of the accident, spondylodesis and dorsal stabilization of TV 4-7 using an internal fixator were carried out and the distal femoral fracture was stabilized with a dynamic condylar screw (DCS). On the day following the accident, the malposition of a pedicle screw located at the height of TV 4 and the borderline malposition of a pedicle screw of TV 7 were corrected. Between the day of the accident and day 8 after, the patient developed impaired vision and in the further course amaurosis associated with fixed pupils. No organopathy could be noticed which could have explained the sudden vision loss. A study of the literature was done, using the keywords "blindness" and "spine surgery." Only very few cases describing a connection of spine surgery and postoperative vision loss could be found. This article aims to elaborate on the few connections worked out in these investigations.

[Post-lobectomy bronchopleural fistula -- a challenge for postoperative intensive care]. / Bronchopleurale Fistel nach Lobektomie -- eine Herausforderung der postoperativen Intensivtherapie.

Bronchopleural fistula (BPF) and bronchial stump insufficiency (BSI) after lobectomies and pneumonectomies are dreaded complications with incidences of up to 12 % and a mortality rate of up to 51 %. Apart from the basic illness causes include complications like aspiration-pneumonia and ARDS, formation of empyema as well as histories of sepsis. Corticoid treatments, old age, diabetes mellitus, previous irradiation as well as post-operative mechanical ventilation (barotrauma) are often counted among contributing causes. Suturing the bronchus and reinforcement by tissue are still the methods of choice, but they are often counter-indicated in high-risk patients. Endoscopic treatments with partial lung occlusions, e. g. by insertion of spongiosa, coils, and/or fibrin glue have been described. However, they require the respective area to be probable. With only one third the rate of success is quite unsatisfactory. The retro-graded instillation of inflammatory-selerotizing substances, like doxycycline, via a chest tube leads to a pleurodesis caused by adhesion of the remaining lung parenchyma to the thoracic wall and a reduction in size of the residual pleural space. In an 82-year old female patient a BPF of the second upper lobe bronchus was detected after a middle lobe resection for abscess and post-radiation ulcer following a mastectomy for carcinoma. The leakage was detected on bronchoscopy by retro-graded instillation via the chest tube of methylene-blue solution into the thoracic cavity. After administering the water-soluble contrast agent amidotrizoic acid in a similar manner a CT confirmed the diagnosis. As the bronchial segment concerned could not be entered selectively, preservation of the right lung lobe's residual ventilation by endoscopic-occlusion procedures was ruled out. Employing a strictly conservative therapy (spontaneous ventilation, retro-graded doxycycline instillations) complete healing with a fully ventilated lower lobe could be achieved over a period of 78 days. BPF as well as residual intro-thoracic cavities after lobectomies pose a serious problem. Using methylene blue for a retro-graded demonstration of BPF during bronchoscopy presents a feasible and cost-efficient diagnostic method. A strictly applied conservative therapy including short-time low-pressure artificial respiration as well as obliteration by fibrous tissue of the thoracic cavity using doxycycline is a feasible procedure for inoperable high-risk patients.

[Emergency room management of multiple injured patients. A multislice computed tomography orientated treatment algorithm]. / Schockraummanagement polytraumatisierter Patienten. Ein Mehrzeilen-CT orientierter Versorgungsalgorithmus.

INTRODUCTION: In the treatment of the seriously injured patient, time is crucial. Clarke et al. showed that in the hypotensive patient with blunt abdominal trauma and bleeding a delay in the surgical treatment over 90 min increases mortality of 1 % every 3 minutes. So called trauma algorithms are used as systematic approach to the seriously injured patient that can be easily reviewed and practiced. One impact of this algorithm is to shorten time in the emergency room and may improve outcome of the patient. The patient outcome is directly related to the length of time between the injury and the beginning to proper definitive care. OBJECTIVE: Are improvements still necessary and possible in the care of the seriously injured patient? New technical developments like multislice-CT are able to shorten time until definitive care. The practicability of an multislice-CT orientated treatment algorithm was evaluated. METHODS: After integration of an multislice-CT into the emergency room the treatment of the seriously injured patient (ISS >16) was changed. Therefore an algorithm which puts the CT diagnostics in the first minutes of the clinical care was developed. RESULTS: 50 patients were treated following the new algorithm. The time in the emergency room decreased from 87 min to 36 min. CONCLUSION: This algorithm requires a differing from previous surgical standards, but it proved to be timesaving, effective and practicable. It makes the beginning of the definitive care possible within the first 40 min after patient arrival in the emergency room.

[D-dimer screening in surgical long-term intensive care patients]. / D-Dimer-Screening bei chirurgischen Langzeitintensivpatienten Erkennung klinisch stummer Thrombosen.

BACKGROUND: Clinically unrecognized thrombosis with the danger of a pulmonary embolism represents an underestimated problem in surgical ICU patients. In patients undergoing total hip replacement for instance, over 30% develop a clinically inapparent form of thrombosis, despite initial thrombosis prophylaxis. We tried to recognize clinically inapparent thrombosis in long-term intensive care patients using D-dimer screening and ultrasound imaging. METHODS: All surgical long-term ICU patients received intravenous heparin 5-10 IU/kg body weight and a D-dimer was assay was carried out every 2 days. If the D-dimer level surpassed 2 mg/l, ultrasound imaging of the veins in the legs, pelvis, arms and neck was performed. RESULTS: Included in the study were 50 patients and D-dimer levels above 2 mg/l were detected in 38%. A thrombosis was proven in 63% of the patients with D-dimer values above 2 mg/l and 50% of the thrombosis were detected in the arm and neck veins very often associated with intravenous catheters. CONCLUSION: Routine D-dimer screening and specific use of ultrasound imaging appears to be a valuable method to verify clinically inapparent thromboses in surgical ICU patients.