[End-of-life decisions and practices in critically ill patients in the cardiac intensive care unit. A nationwide survey]. / Begrenzung und Abbruch lebenserhaltender Maßnahmen bei kritisch kranken kardiochirurgischen Patienten. Ergebnisse einer bundesweiten Umfrageaktion.

BACKGROUND: Ethical and medical criteria in the decision-making process of withholding or withdrawal of life support therapy in critically ill patients present a great challenge in intensive care medicine. OBJECTIVES: The purpose of this work was to assess medical and ethical criteria that influence the decision-making process for changing the aim of therapy in critically ill cardiac surgery patients. MATERIALS AND METHODS: A questionnaire was distributed to all German cardiac surgery centers (n = 79). All clinical directors, intensive care unit (ICU) consultants and ICU head nurses were asked to complete questionnaires (n = 237). RESULTS: In all, 86 of 237 (36.3 %) questionnaires were returned. Medical reasons which influence the decision-making process for changing the aim of therapy were cranial computed tomography (cCT) with poor prognosis (91.9 %), multi-organ failure (70.9 %), and failure of assist device therapy (69.8 %). Concerning ethical reasons, poor expected quality of life (48.8 %) and the presumed patient's wishes (40.7 %) were reported. There was a significant difference regarding the perception of the three different professional groups concerning medical and ethical criteria as well as the involvement in the decision-making process. CONCLUSION: In critically ill cardiac surgery patients, medical reasons which influence the decision-making process for changing the aim of therapy included cCT with poor prognosis, multi-organ failure, and failure of assist device therapy. Further studies are mandatory in order to be able to provide adequate answers to this difficult topic.

Influence of storage time and amount of red blood cell transfusion on postoperative renal function: an observational cohort study.

INTRODUCTION: To identify the impact of storage time and amount of transfused red blood cell units on renal function. METHODS: Consecutive transfused patients (n=492), undergoing cardiac surgery at a single centre and receiving at least one red blood cell unit, were pooled in different groups depending on storage time and amount of transfusion. RESULTS: Altogether 2,133 red blood cell units were transfused (mean age 21.87 days). Pre- and intraoperative data were similar between groups. Postoperative serum creatinine (p<0.01), glomerular filtration rate (p<0.01), and urea (p<0.01) showed a significant correlation with the amount of transfused red blood cell units, but not with storage time. Acute kidney insufficiency (creatinine values greater than 2.0 mg/dl or a duplication of the preoperative value) developed in 29% of patients and was associated with red blood cell mean age (p=0.042), absolute age (p=0.028), and amount of transfused (p<0.01) units. Acute kidney failure requiring renal replacement therapy occurred in 9.6% of patients and was associated with the amount of transfusion (p<0.01).  CONCLUSIONS: Worsening of renal function after cardiac surgery is associated with storage time and amount of transfused red blood cell units. Acute kidney insufficiency was defined as serum creatinine values greater than 2.0 mg/dl or a duplication of the preoperative value (baseline). Acute kidney failure was defined as becoming dependent upon dialysis.

Management of poststernotomy mediastinitis: experience and results of different therapy modalities.

BACKGROUND: Different primary treatment modalities have been utilized to treat poststernotomy mediastinitis (PM) following cardiac surgery. METHODS: A literature survey using the key phrases "treatment of deep sternal wound infection" and "poststernotomy-mediastinitis" was performed. Furthermore, a questionnaire regarding the primary treatment of PM was distributed to all 79 German heart surgery centers. RESULTS: The review of the literature shows that the current understanding is based purely on retrospective studies, not on evidence-based medicine. All 79 German heart centers replied to the questionnaire. Vacuum-assisted closure therapy (V. A. C.(R)) is used in 28/79 (35 %) heart centers as the "first-line" treatment, 22/79 (28 %) perform primary reclosure in conjunction with a double-tube irrigation/suction system, and in 29/79 (37 %) German heart centers both treatment options were used according to the intraoperative conditions. CONCLUSIONS: As a primary treatment for PM two treatment modalities are currently in use: primary reclosure coupled with a double-tube suction/irrigation system versus V. A. C.(R) therapy. Since prospective randomized studies have not yet been performed, controlled clinical trials comparing both treatment modalities are pivotal to define the evidence for patients presenting with PM.