[The role of intensive care medicine in early postoperative complications. Is surgical expertise in danger?]. / Rolle der Intensivmedizin bei frühen postoperativen Komplikationen. Ist die chirurgische Expertise in Gefahr?

Intensive care medicine is the backbone of surgery. We describe a profile of parameters which has to be repeatedly evaluated to allow early detection of postoperative complications. Complex surgical diseases are analyzed to underscore that only a surgeon experienced in intensive care medicine is able to interpret abnormalities in correlation with the intra-operative findings resulting in appropriate decisions with respect to diagnostic measures and reintervention. An increasing lack of motivation compromises the necessary training of young surgeons. Work hour limits already prolong education in the operative core competence thus making residents decline a necessary extension of ICU training beyond the compulsory 6 months. Identification of young surgeons with intensive care medicine is further hampered by the establishment of interdisciplinary operative ICUs excluding surgeons from the leadership. Our current survey of 38 university departments of general and gastro-intestinal surgery in Germany shows that a cooperative ICU steering structure of anesthesiologists and surgeons exists in only 19%. The imminent deficit of training in surgical intensive care medicine can only be counteracted by equal leadership structures.

[Microcirculatory failure of sublingual perfusion in septic-shock patients. Examination by OPS imaging and PiCCO monitoring]. / Sublinguale Mikrozirkulationsstörungen bei Patienten im septischen Schock: Untersuchungen mittels OPS-Imaging-System und PiCCO-Monitoring.

BACKGROUND: Haemodynamic monitoring of septic patients is impeded by the discrepancy between the macrohaemodynamics and the microcirculation of internal organs. Pulse contour analysis (PiCCO) provides new parameters for an improved assessment of the volume status of critically ill patients. However, changes in regional circulation, in particular those affecting the splanchnic perfusion, have proven to be especially important. The aim of our study was to compare macrohaemodynamic parameters (PiCCO) with microcirculation (OPS imaging) in severely septic patients with multiple organ failure. PATIENTS AND METHODS: In seven patients suffering from septic shock and multiple organ failure (APACHE II score > 25) repeated examinations at a twenty-four hour interval were carried out by PiCCO monitoring and OPS imaging. OPS data were recorded for twenty seconds at 6 different buccal and sublingual localisations, adequately reflecting microvascular perfusion of the liver and the small intestine. Data were videotaped for off-line analysis, calculating current velocity in small and large venules (< 25 and > 25 microm), as well as functional capillary density. RESULTS: Significant correlations were found for current velocity in small venules with systemic vascular resistance (r(2) = 0.252, p < 0.05), mean arterial blood pressure (r(2) = 0.259, p < 0.05), and pH value (r(2) = 0.265, p < 0.05). In addition, a significant correlation was found between the oxygen transport index and the density of small vessels (r(2) = 0.355; p < 0.05). CONCLUSION: According to our findings, data acquired through PiCCO monitoring may be used for a rough estimation of the microcirculation during severe sepsis and multiple organ failure. For an assessment of the local conditions of perfusion, however, there are limits in the use of the parameters that were the object of our research. For the measurement at localisations which are accessible non-invasively and representative of the splanchnic perfusion, OPS is the more accurate method for characterisation of the microcirculation, although a more extensive and time-consuming analysis is needed.

[Fungemia after oral treatment with Saccharomyces boulardii in a patient with multiple comorbidities]. / Fungämie nach oraler Gabe von.

HISTORY AND CLINICAL FINDINGS: A 48-year-old diabetic with multiple co-morbidities presented with generalized micro- and macroangiopathy including peripheral artery disease stage IV with necroses in several digits of both feet. He was admitted to the department of surgery for the insertion of femoropopliteal bypasses. INVESTIGATIONS: Infectious parameters were elevated (CRP 66.1 mg/l, sedimentation rate 90/96), accompanied by anemia (Hb 7.1 mmol/l), leukocytosis (14.8 Gpt/l) and thrombocytosis (514 Gpt/l). Body temperature was normal (36.8 degrees C). With insulin treatment the patient became nearly normoglycemic (HbA1c 6.8 %). TREATMENT AND FOLLOW UP: After receiving different broad-spectrum antibiotics over seven weeks the patient developed Clostridium difficile toxin-positive diarrhea that resolved after administration of oral metronidazole and Saccharomyces boulardii (Perenterol ((R))). Three days after bypass insertion, both legs had to be amputated due to infection and beginning sepsis. The condition of the patient improved. However, eight days after bypass-insertion the patient developed a toxic megacolon and sepsis. Blood cultures yielded the growth of Saccharomyces cerevisae. Despite of intensive care treatment the patient died five days later from to multi-organ failure. CONCLUSION: S. boulardii (synonym: S. cerevisiae) is considered an non-pathogenic probiotic yeast, and live yeast cells are used for supportive therapy of diarrhea. The present case and a review of the literature demonstrate that fungemia and sepsis are rare complications of the administration of S. boulardii in immunocompromised patients. For this reason the therapeutic usage of probiotics should be carefully considered regarding its risk-benefit potential.

[Bipolar impulses or direct current as an adjuvant treatment of incisional hernia? Comparative experimental animal study]. / Bipolare Impulse oder Gleichstrom als adjuvante Behandlung von Narbenhernien? Tierexperimentelle Vergleichsuntersuchungen.

The electrostimulation of the cicatricial healing in the abdominal wall were tested in 119 Wistar rats by means of bipolar rectangularly pulsed current (0.87 Hz, +/- 25 mu A) and direct current (1 mu A). Doubling of the fascia of an abdominal wall hernia was carried out in three groups of rats. In the first group the operational region was stimulated by rectangularly pulsed current, strong proliferated cicatrices were formed with premature production of fibroblasts and collagenous fibres, fast maturation, and high strength. In the second group it was stimulated by direct current, a less exact longitudinal orientation of the collagenous fibres and a slower cicatricial maturation were shown. The third group applied as a control showed a cicatricial distension up to 5 mm. The electrostimulation of the proliferation of connective tissue and cicatricial healing could be pointed out between different tissues (peritoneum and fascia).