Levosimendan in intensive care and emergency medicine: literature update and expert recommendations for optimal efficacy and safety.

The inodilator levosimendan, in clinical use for over two decades, has been the subject of extensive clinical and experimental evaluation in various clinical settings beyond its principal indication in the management of acutely decompensated chronic heart failure. Critical care and emergency medicine applications for levosimendan have included postoperative settings, septic shock, and cardiogenic shock. As the experience in these areas continues to expand, an international task force of experts from 15 countries (Austria, Belgium, China, Croatia, Finland, France, Germany, Greece, Hungary, Italy, the Netherlands, Spain, Sweden, Switzerland, and the USA) reviewed and appraised the latest additions to the database of levosimendan use in critical care, considering all the clinical studies, meta-analyses, and guidelines published from September 2019 to November 2021. Overall, the authors of this opinion paper give levosimendan a "should be considered" recommendation in critical care and emergency medicine settings, with different levels of evidence in postoperative settings, septic shock, weaning from mechanical ventilation, weaning from veno-arterial extracorporeal membrane oxygenation, cardiogenic shock, and Takotsubo syndrome, in all cases when an inodilator is needed to restore acute severely reduced left or right ventricular ejection fraction and overall haemodynamic balance, and also in the presence of renal dysfunction/failure.

[Perioperative optimization using hemodynamically focused echocardiography in high-risk patients-A practice guide]. / Perioperative Optimierung mittels auf die Hämodynamik fokussierter Echokardiographie bei Hochrisikopatienten ­ eine Praxisanleitung.

BACKGROUND: The number of high-risk patients undergoing surgery is steadily increasing. In order to maintain and, if necessary, optimize perioperative hemodynamics as well as the oxygen supply to the organs (DO2) in this patient population, a timely assessment of cardiac function and the underlying pathophysiological causes of hemodynamic instability is essential for the anesthesiologist. A variety of hemodynamic monitoring procedures are available for this purpose; however, due to method-immanent limitations they are often not able to directly identify the underlying cause of cardiovascular impairment. OBJECTIVE: To present a stepwise algorithm for a perioperative echocardiography-based hemodynamic optimization in noncardiac surgery high-risk patients. In this context, echocardiography on demand according to international guidelines can be performed under certain conditions (hemodynamic instability, nonresponse to hemodynamic treatment) as well as in the context of a planned intraoperative procedure, mostly as a transesophageal echocardiography. METHODS AND RESULTS: Hemodynamically focused echocardiography as a rapidly available bedside method, enables the timely diagnosis and assessment of cardiac filling obstructions, volume status and volume response, right and left heart function, and the function of the heart valves. CONCLUSION: Integrating all echocardiographic findings in a differentiated assessment of the patient's cardiovascular function enables a (patho)physiologically oriented and individualized hemodynamic treatment.

Perioperative echocardiography-guided hemodynamic therapy in high-risk patients: a practical expert approach of hemodynamically focused echocardiography.

The number of high-risk patients undergoing surgery is growing. To maintain adequate hemodynamic functioning as well as oxygen delivery to the vital organs (DO2) amongst this patient population, a rapid assessment of cardiac functioning is essential for the anesthesiologist. Pinpointing any underlying cardiovascular pathophysiology can be decisive to guide interventions in the intraoperative setting. Various techniques are available to monitor the hemodynamic status of the patient, however due to intrinsic limitations, many of these methods may not be able to directly identify the underlying cause of cardiovascular impairment. Hemodynamic focused echocardiography, as a rapid diagnostic method, offers an excellent opportunity to examine signs of filling impairment, cardiac preload, myocardial contractility and the function of the heart valves. We thus propose a 6-step-echocardiographic approach to assess high-risk patients in order to improve and maintain perioperative DO2. The summary of all echocardiographic based findings allows a differentiated assessment of the patient's cardiovascular function and can thus help guide a (patho)physiological-orientated and individualized hemodynamic therapy.

[Prehospital management of acute coronary syndrome in patients on long-term direct oral anticoagulant treatment]. / Prähospitale Behandlung des akuten Koronarsyndroms unter DOAK-Dauertherapie.

BACKGROUND: Despite an increasing incidence of patients suffering from acute coronary syndrome (ACS) under simultaneous treatment with direct oral anticoagulants (DOAC), neither sufficient scientific data nor uniform guidelines for the anticoagulation treatment of these patients are currently available. OBJECTIVE: The aim of this study was to determine the current practice of preclinical treatment of ACS in patients under DOAC treatment. MATERIAL AND METHODS: An internet and paper-based survey of emergency physicians, specialists of internal medicine, anesthesiologists, emergency and intensive care physicians was performed concerning the prehospital treatment of ACS in patients under long-term DOAC treatment. RESULTS: Overall, 284 questionnaires were answered. Substantial differences in the current treatment of ACS under long-term DOAC therapy were identified. While 39% of the respondents stated that they administer a combination treatment of heparin and acetylsalicylic acid (ASA), 36% renounced the administration of heparin. If a dose reduction was performed, 71% answered that they reduce the heparin dosage. Also, in cases of ST-segment elevation myocardial infarction 48% of the physicians renounced the administration of heparin. CONCLUSION: In Germany there is currently a heterogeneous practice of emergency treatment of ACS patients under DOAC therapy with respect to the administration of heparin and ASA. Therefore, guidelines of the specialist medical societies should address the prehospital emergency anticoagulation management of ACS in patients under therapy with DOAC, which correspond to the needs of patients and emergency physicians.

[Apnea test for assessment of brain death under extracorporeal life support]. / Apnoetest beim irreversiblen Hirnfunktionsausfall unter extrakorporaler Zirkulation.

BACKGROUND: The fourth edition of the German guideline for the assessment of brain death, published in 2015 by the German Medical Council (Bundesärztekammer), emphasizes the importance of an apnea test. It is also now required under all circumstances of extracorporeal life support. OBJECTIVES: This article is an instruction for the guideline-conforming performance of an apnea test in general and also in cases of extracorporeal life support in different configurations. MATERIALS AND METHODS: A literature review was performed. CONCLUSIONS: The apnea test is an essential part of the bedside examination for the clinical diagnosis of brain death. It is required for all kinds of extracorporeal life support and can be easily performed without endangering the patient. More accurate recommendations for its performance should be considered for the next version of the German guideline for brain death assessment.

[New technical developments for inhaled sedation]. / Neue technische Entwicklungen der inhalativen Sedierung.

The circle system has been in use for more than 100 years, whereas the first clinical application of an anaesthetic reflector was reported just 15 years ago. In the circle system, all breathing gas is rebreathed after carbon dioxide absorption. A reflector, on the other hand, with the breathing gas flowing to and fro, specifically retains the anaesthetic during expiration and resupplies it during the next inspiration. A high reflection efficiency (number of molecules resupplied/number of molecules exhaled, RE 80-90%) decreases consumption. In analogy to the fresh gas flow of a circle system, pulmonary clearance ((1-RE) × minute ventilation) defines the opposition between consumption and control of the concentration.It was not until reflection systems became available that volatile anaesthetics were used routinely in some intensive care units. Their advantages, such as easy handling, and better ventilatory capabilities of intensive care versus anaesthesia ventilators, were basic preconditions for this. Apart from AnaConDa™ (Sedana Medical, Uppsala, Sweden), the new MIRUS™ system (Pall Medical, Dreieich, Germany) represents a second, more sophisticated commercially available system.Organ protective effects, excellent control of sedation, and dose-dependent deep sedation while preserving spontaneous breathing with hardly any accumulation or induction of tolerance, make volatile anaesthetics an interesting alternative, especially for patients needing deep sedation or when intravenous drugs are no longer efficacious.But obviously, the outcome is most important. We know that deep intravenous sedation increases mortality, whereas inhalational sedation could prove beneficial. We now need prospective clinical trials examining mortality, but also the psychological outcome of those most critically ill patients sedated by inhalation or intravenously.

[Penetrating injury of two body cavities with a 20 cm long dagger-like sliver after falling into a glass door]. / Penetrierende 2-Höhlen-Verletzung mit einer 20 cm langen dolchartigen Scherbe nach Sturz in eine Glastür.

In Germany the numbers of penetrating thoracic injuries are rare compared to Anglo-American countries; however, the number of cases has increased in recent years due to an increase in violent incidents. This article reports the case of a patient who suffered such a penetrating thoracic injury after a domestic accident. Operative treatment was performed according to the well-established standard treatment algorithms. Contrary to the initial assessment of the emergency doctor, substantially more severe injuries were found.

A scoring system for the assessment of angiographic findings in non-occlusive mesenteric ischemia (NOMI).

PURPOSE: To establish a standardized scoring system for angiographic findings in patients with non-occlusive mesenteric ischemia (NOMI). MATERIALS AND METHODS: In 36 patients (mean age: 72 years), 53 angiographies of the superior mesenteric artery (SMA) were performed for suspected NOMI after cardiac or major aortic surgery. All examinations were performed using a standardized DSA technique. Two experienced radiologists performed a consensus reading blinded to the clinical information, on two occasions with an interval of two weeks. In order to investigate the reproducibility of the criteria, the images were assessed once by an intensivist and a medical student. Image analysis was performed with respect to vessel morphology, reflux of contrast medium into the aorta, small bowel parenchymal contrast enhancement and distension and the delay between arterial injection and portal vein filling. RESULTS: Almost perfect intra-observer correlation was obtained for the assessment of the contrast medium reflux (κ = 0.82) and substantial correlation for the time of portal vein filling (κ = 0.66). Moderate correlations were obtained for the vessel morphology (κ = 0.51), small bowel enhancement (κ = 0.63) and distension (κ = 0.53). Contrast medium reflux into the aorta (κ = 0.77 and 0.63) and the time of portal vein filling (κ = 0.42 and 0.58) resulted in the highest inter-observer correlations between the radiologists and the intensivist as well as the radiologists and the student. CONCLUSION: In patients with suspected NOMI, using our scoring system yields high intra- and inter-observer correlations, allowing a standardized evaluation of angiographic findings.

Relationship between mixed venous oxygen saturation and regional cerebral oxygenation in awake, spontaneously breathing cardiac surgery patients.

BACKGROUND: In search of a non-invasive method for estimation of the oxygen balance this prospective study evaluates the relationship between regional cerebral oxygenation (rScO2) and mixed venous oxygen saturation in awake, spontaneously breathing patients after cardiac surgery. METHODS: After approval by the local ethical committee and written informed consent, 26 consecutive patients after cardiac surgery with cardiopulmonary bypass were enrolled. On intensive care unit (ICU), several hours after extubation, patients were connected to the INVOS 5100 cerebral monitor. Blood samples for determination of mixed venous oxygen saturation (SvO2) and central venous oxygen saturation (ScvO2) were drawn successively and rScO2 was documented. Patients were studied twice, breathing room air for the first measurement cycle, and breathing 4L/min supplemental oxygen by face mask, achieving a transcutaneous oxygen saturation above 98%, for a second measurement. RESULTS: Hemodynamic variables, hemoglobin and arterial carbon dioxide tension (PaCO2) remained stable between the two measurement cycles. Without oxygen, SvO2 and rScO2 showed a bias of -2.0%, limits of agreement (LOA) of -15.0 to 10.9% and a percentage error (PE) of 20.3%. SvO2 and ScvO2 showed a bias of -3.9%, LOA of -13.9 to 6.2% and PE 15.7%. With oxygen, the bias between SvO2 and rScO2 was -2.5%, LOA -14.2 to 9.2%, PE 17.2%. Between SvO2 and ScvO2 the bias was -4.1%, LOA -10.2 to 2.1%, PE 9.0%. CONCLUSION: The rScO2 measured by near infrared spectroscopy was sufficiently representing mixed venous oxygen saturation in awake, hemodynamically stable, spontaneously breathing patients after cardiac surgery. The agreement was comparable to the agreement between SvO2 and ScvO2 with smaller differences in the lower ranges of SvO2.

Lack of agreement between pulmonary arterial thermodilution cardiac output and the pressure recording analytical method in postoperative cardiac surgery patients.

BACKGROUND: Pulse-contour analysis method (PCM) cardiac output (CO) monitors are increasingly used for CO monitoring during anaesthesia and in the critically ill. Very recently, several systems have been introduced that do not need calibration; among them the pressure recording analytical method (PRAM). Sparse data comparing the accuracy of the PRAM-CO with conventional thermodilution CO (ThD-CO) in cardiac surgery patients are available. METHODS: In this prospective comparison study, paired CO measurements with a pulmonary artery catheter and a PRAM monitoring set were obtained 20-30 min apart (t1, t2) in 23 extubated patients on the first postoperative day after cardiac surgery. Data were analysed by the Bland-Altman method. RESULTS: A total of 46 paired CO measurements (23 for each interval) were collected. The Bland-Altman analysis showed a mean difference (bias) of 0.0 litre min(-1) and limits of agreement (1.96 sd) of 4.53 to -4.54 litre min(-1) [upper 95% confidence interval (CI), 3.26-5.80; lower 95% CI, -5.8 to -3.27]. The percentage error (1.96 sd/mean of the reference method) was 87%. CONCLUSIONS: These results question the reliability of the PRAM technology for the determination of CO in postoperative cardiac surgery patients.

[Anti-inflammatory effects of pentoxifylline: importance in cardiac surgery]. / Antiinflammatorische Effekte von Pentoxifyllin : Bedeutung bei herzchirurgischen Eingriffen.

Initially introduced as a rheologic agent for use in intermittent claudication due to peripheral artery disease and in ischemic cerebrovascular disease, the methylxanthine derivative pentoxifylline (PTX) has been shown to possess several anti-inflammatory properties which make this drug an interesting immunomodulating adjunct for the management of patients undergoing cardiac surgery. As an unspecific phosphodiesterase inhibitor PTX ameliorates the inflammatory response following a septic stimulus and blunts organ dysfunction after ischemia-reperfusion injury. Apart from this several small clinical studies have shown that the use of PTX may blunt the inflammatory response induced by cardiac surgery using a cardiopulmonary bypass. Additionally it has been shown that the perioperative application of this drug may improve postoperative function of organs at risk, such as the kidneys and liver.

[Quality in aortic valve replacement--how good have hybrid valves have to be?]. / Qualität der chirurgischen Behandlung von Aortenklappenvitien. Welche Verbesserungen sind von Hybridklappen zu erwarten?

The current enthusiasm with the development of catheter-based aortic valve replacement suggests a critical appraisal of the quality of conventional techniques. Currently surgical treatment of diseased aortic valves includes different methods that can be employed with a low risk. Risk prediction is difficult, the Euroscore largely overestimates mortality. By comparison, there is no evidence that the risk of implantation is reduced by catheter-based implantation. Specific complications (stroke, AV-block, perivalvular leak) are more frequent compared to conventional replacement. Despite the current enthusiasm over the feasibility of catheter-based implantation of hybrid aortic valves they should still be used cautiously.

Late perforation of a right ventricular pacing lead: a potentially dangerous complication.

Four days after uncomplicated implantation of a two-chamber pacemaker and a normal postoperative course, a patient was referred to our hospital with left-sided hemothorax and early hemorrhagic shock. Chest X-ray and CT scan were suspicious of a right ventricular lead perforation with additional pericardial and pleural injury. Immediate surgery was performed via a lateral thoracotomy and the perforation was repaired via direct suture. An epimyocardial ventricular lead was implanted simultaneously. The patient made an uneventful recovery.

Comparison of oesophageal and gastric air tonometry in patients with circulatory failure.

BACKGROUND: Gastric PCO2 measured by balloon tonometry can estimate the adequacy of splanchnic perfusion. However, enteral feeding and gastric content can interfere with gastric PCO2 assessment. Tonometry in other sites of the body could avoid these problems. We therefore tested the hypothesis that oesophageal air tonometry would give results similar to gastric tonometry. METHODS: We studied 20 consecutive patients (mean age 68 (SD 9) [range 49-81] yr, 18 males, SAPS II score 55 (SD 18), ICU mortality 55%) with circulatory disorders during mechanical ventilation in the intensive care unit. Tonometer probes were placed via the nose, one into the stomach and the other in the oesophagus. PCO2 was measured with two automated gas analysers, at admission and 30 min, 1, 2, 3, 32, 40, and 48 h thereafter. RESULTS: One hundred and forty-eight paired measurements were obtained. Gastric PCO2 was greater than oesophageal PCO2 on admission (7.19 (1.43) vs 5.89 (0.73) kPa, P < 0.01) and subsequently. Differences between the measures correlated (r = 0.67) with the mean absolute value, indicating that overestimation increased as gastric PCO2 increased. CONCLUSIONS: Oesophageal PCO2 is less than gastric PCO2, and the difference is greater when gastric PCO2 levels are greater. Air tonometry may not measure regional PCO2 levels in the oesophagus satisfactorily. Other methods and sites for carbon dioxide tonometry should be examined.

Tissue engineering: complete autologous valve conduit--a new moulding technique.

OBJECTIVE: The use of fibrin gel, which can be produced from patients' blood, was investigated as an autologous, biodegradable scaffold. A new moulding technique was developed to create a complete aortic root. METHODS: A new moulding technique was generated for the creation of complete valve conduit. On the basis of biomechanical valve design studies, a tricuspid "ventricular" and "aortic" stamp were developed. A silicone-coated aluminum cylinder was used to circumferentially limit the mould. The cell/gel suspension was filled into the mould and polymerization was started. RESULTS: The creation of complex structures such as complete valve conduits is possible with the moulding technique described. With a layer thickness of up to 2 mm, histological investigations showed excellent tissue development with viable fibroblasts surrounded by collagen bundles. CONCLUSION: Fibrin gel unifies many properties of an ideal scaffold: The formation of complex structures is possible, the degradation and polymerization is controllable and the formation of the extracellular matrix is excellent.

Thrombosis in Behcet's disease: report of a case followed by a systematic review using the methodology of evidence-based medicine.

BACKGROUND: Behcet's disease (BD) is a rare systemic inflammatory disease of unknown aetiology with a variety of organ manifestations. METHODS: A case of Behcet's disease complicated by deep vein thrombosis (DVT) and inferior vena cava thrombosis referred to our institution is reported. In addition, a structured literature search using the methodology of evidence-based medicine for the localization of venous lesions, treatment modalities, and outcome of patients with Behcet's disease and concurrent thrombosis was performed. A modified validity score was assigned by established methods. RESULTS: In total, 214 citations were identified using our search strategy. Among these citations, 10 papers including a total of 32 patients (25 male, 7 female) met the inclusion criteria and were incorporated into this overview together with our patient. All studies consisted of serial case reports without control subjects. Neither localization of venous lesions, nor treatment modalities were homogeneous not allowing general recommendations. CONCLUSIONS: No data are available from controlled studies regarding treatment modalities of patients presenting with Behcet's disease complicated by concurrent thrombosis. This lack of evidence implicates the need for large scale and co-ordinated registries including data on the acute treatment as well as the prevention of future thrombotic events in this clinical setting. The diagnostic criteria of the "International Study Group for Behcet's Disease" may well serve as a basis for this approach.