C. Hainer

Tigecycline for the treatment of patients with severe sepsis or septic shock: a drug use evaluation in a surgical intensive care unit

OBJECTIVES Adequate antimicrobial therapy is crucial for the survival of critically ill patients with severe nosocomial infections. Tigecycline, the first available agent in the new class of glycylcyclines, is active against multiresistant gram-positive and gram-negative bacteria. The aim of this observational, retrospective evaluation was to assess tigecycline use patterns in a surgical intensive care unit (SICU) of a tertiary care centre. METHODS Data from 70 patients receiving tigecycline in the SICU were analysed. We reviewed tigecycline use in terms of demographic data and co-morbidities, disease severity, clinical indication, microbiology, therapy regimens and mortality. A logistic regression analysis was performed to identify prognostic factors for mortality. RESULTS The majority of patients had co-morbidities such as cancer (51%) or renal replacement therapy (57%). The mean Acute Physiology and Chronic Health Evaluation (APACHE) II score of patients at admission was 27. Intra-abdominal infection was most frequently diagnosed (50% of patients); intra-abdominal infection and pneumonia were diagnosed in 14%. Methicillin-resistant Staphylococcus aureus was found in 16% of patients (colonization; infection: 6%) and vancomycin-resistant enterococci in 27% (colonization; infection: 21%). The mean duration of tigecycline therapy was 9 +/- 4 days; 76% of patients received tigecycline in combination, with 64% being treated second line. APACHE score and renal replacement were identified as predictive factors for mortality. SICU mortality was 30%. CONCLUSIONS Tigecycline treatment of critically ill SICU patients with severe sepsis or septic shock appeared to result in remarkably low mortality. Tigecycline may be an important treatment option for septic patients with infections resistant to other available agents.

Patientenspektrum im Notarztdienst

ZusammenfassungHintergrundBundesdeutsche Notarzt(NA)-Systeme vermelden über die Jahre hinweg steigende Einsatzzahlen. Ziel der Untersuchung war es, die Entwicklung des Patientenspektrums eines NA-Systems über einen Zeitraum von 20 Jahren zu evaluieren, um die wesentlichen Veränderungen aufzuzeigen.Material und MethodeIn einer retrospektiven Untersuchung wurden die Einsatzprotokolle der Jahrgänge 2004, 1992 und 1984 hinsichtlich Demographie, Einsatzkategorien, Erkrankungs-/Verletzungsschwere (NACA), Bewusstseinslage (GCS) und notärztlichen Maßnahmen analysiert. Ergebnisse Im Jahr 2004 (3825) gab es im Vergleich zu 1992 (2114) und 1984 (957) das 2- bzw. 4-fache an Einsätzen. In allen drei untersuchten Zeiträumen waren nichttraumatologische (74%; 2812 vs. 66%; 1390 vs. 51%; 485) vor traumatologischen Einsätzen (18%; 690 vs. 22%; 464 vs. 39%; 375), Fehlfahrten (3%; 126 vs. 7%; 154 vs. 6%; 56) und Todesfeststellungen (5%; 197 vs. 5%; 106 vs. 4%; 41) führend. Obwohl der prozentuale Anteil der Patienten mit NACA IV–VI (39% vs. 50 %) und der Patienten mit GCS ≤8 (18% vs. 34%) im Jahr 2004 niedriger war, lagen auch hier die Absolutzahlen über denen von 1984 (NACA IV–VI: 1434 vs. 448, p<0,01; GCS: 672 vs. 303, p<0,01).SchlussfolgerungDie Untersuchung zeigt, dass heute der prozentuale Anteil von traumatologischen, schwer erkrankten/–verletzten und schwer bewusstseinsgestörten Notfallpatienten niedriger ist als in den vorangegangenen Jahren. Die höheren absoluten Patientenzahlen zeigen jedoch, dass der NA heute insgesamt einer größeren Zahl sowohl vital-bedrohter, schwer bewusstseinsgetrübter und traumatologischer Patienten begegnet. Prozentuale Änderungen über die Jahre hinweg dürfen jedoch nicht dazu führen, die bisher für das Management akut vital bedrohter Patienten als notwendig erachtete notärztliche Qualifikation in Frage zu stellen.AbstractBackgroundIn Germany the physician staffed emergency systems have announced an increase in rescue missions over the years. The aim of this study is to analyse the development of the spectrum of patients in an emergency system over the last 20 years in order to highlight the significant changes.MethodsIn a retrospective study we analyzed the prehospital chart views from 2004, 1992 and 1984 with respect to patients’ demography, type of rescue mission, degree of internal disease or injury (NACA), state of consciousness (GCS), as well as prehospital interventions perfomed by prehospital emergency physician.ResultsIn 2004 (3,825), the absolute number of missions was 2 and 4 times higher than 1992 (2,114) and 1984 (957), resp. In all of these investigated time periods non-trauma missions (74%; 2,812 vs. 66%; 1,390 vs. 51%; 485) were leading, followed by trauma missions (18%; 690 vs. 22%; 464 vs. 39%; 375), aborted missions (3%; 126 vs. 7%; 154 vs. 6%; 56), and dead on arrival (5%; 197 vs. 5%; 106 vs. 4%; 41). Although, the percentage of patients with NACA IV–VI (39% vs. 50%) or patients with GCS ≤8 (18% vs. 34%) was lower in 2004, the absolute number of patients in each categorie was higher than in 1984 (NACA IV–VI: 1,434 vs. 448, p<0.01; GCS: 672 vs. 303, p<0.01).ConclusionsThe results of this study demonstrate, that the percentage of trauma, severely ill/injured or unconscious patients is lower than in previous years. However, the higher absolute numbers of patients demonstrate that the emergency physician now encounters more critically ill/injured, unconscious and trauma patients. It does not seem necessary to question the qualifications for an emergency physician, which have previously been considered essential for the management of acute life-threatening situations.

Left ventricular end-diastolic area is a measure of cardiac preload in patients with early septic shock.

Background and objective Central venous pressure, intrathoracic blood volume, and left ventricular end-diastolic area are reliable measures of cardiac preload under stable clinical conditions. The purpose of this study was to compare different preload parameters over 24 h under conditions of multiple, frequently changing treatments in early septic shock. Methods In 28 mechanically ventilated patients within 6 h of the onset of septic shock, left ventricular end-diastolic area was measured using transoesophageal echocardiography. Intrathoracic blood volume, stroke volume variation, and central venous pressure were analysed as preload parameters. The relation between parameter changes and changes in therapy was examined with respect to cardiac index and stroke volume index. Results Regarding preload variables, linear regression analyses revealed a significant correlation between left ventricular end-diastolic area and stroke volume index (r2 = 0.59, P < 0.001) and cardiac index (r2 = 0.41, P < 0.001), respectively. Changes in left ventricular end-diastolic index and intrathoracic blood volume index reflected changes in the stroke volume index, whereas central venous pressure did not. Myocardial responsiveness also failed to predict changes in the stroke volume index. Conclusion Only the left ventricular end-diastolic area index may help predict preload in ventilated patients with early septic shock.

Spectrum of patients in prehospital emergency services. What has changed over the last 20 years

ZusammenfassungHintergrundBundesdeutsche Notarzt(NA)-Systeme vermelden über die Jahre hinweg steigende Einsatzzahlen. Ziel der Untersuchung war es, die Entwicklung des Patientenspektrums eines NA-Systems über einen Zeitraum von 20 Jahren zu evaluieren, um die wesentlichen Veränderungen aufzuzeigen.Material und MethodeIn einer retrospektiven Untersuchung wurden die Einsatzprotokolle der Jahrgänge 2004, 1992 und 1984 hinsichtlich Demographie, Einsatzkategorien, Erkrankungs-/Verletzungsschwere (NACA), Bewusstseinslage (GCS) und notärztlichen Maßnahmen analysiert. Ergebnisse Im Jahr 2004 (3825) gab es im Vergleich zu 1992 (2114) und 1984 (957) das 2- bzw. 4-fache an Einsätzen. In allen drei untersuchten Zeiträumen waren nichttraumatologische (74%; 2812 vs. 66%; 1390 vs. 51%; 485) vor traumatologischen Einsätzen (18%; 690 vs. 22%; 464 vs. 39%; 375), Fehlfahrten (3%; 126 vs. 7%; 154 vs. 6%; 56) und Todesfeststellungen (5%; 197 vs. 5%; 106 vs. 4%; 41) führend. Obwohl der prozentuale Anteil der Patienten mit NACA IV–VI (39% vs. 50 %) und der Patienten mit GCS ≤8 (18% vs. 34%) im Jahr 2004 niedriger war, lagen auch hier die Absolutzahlen über denen von 1984 (NACA IV–VI: 1434 vs. 448, p<0,01; GCS: 672 vs. 303, p<0,01).SchlussfolgerungDie Untersuchung zeigt, dass heute der prozentuale Anteil von traumatologischen, schwer erkrankten/–verletzten und schwer bewusstseinsgestörten Notfallpatienten niedriger ist als in den vorangegangenen Jahren. Die höheren absoluten Patientenzahlen zeigen jedoch, dass der NA heute insgesamt einer größeren Zahl sowohl vital-bedrohter, schwer bewusstseinsgetrübter und traumatologischer Patienten begegnet. Prozentuale Änderungen über die Jahre hinweg dürfen jedoch nicht dazu führen, die bisher für das Management akut vital bedrohter Patienten als notwendig erachtete notärztliche Qualifikation in Frage zu stellen.AbstractBackgroundIn Germany the physician staffed emergency systems have announced an increase in rescue missions over the years. The aim of this study is to analyse the development of the spectrum of patients in an emergency system over the last 20 years in order to highlight the significant changes.MethodsIn a retrospective study we analyzed the prehospital chart views from 2004, 1992 and 1984 with respect to patients’ demography, type of rescue mission, degree of internal disease or injury (NACA), state of consciousness (GCS), as well as prehospital interventions perfomed by prehospital emergency physician.ResultsIn 2004 (3,825), the absolute number of missions was 2 and 4 times higher than 1992 (2,114) and 1984 (957), resp. In all of these investigated time periods non-trauma missions (74%; 2,812 vs. 66%; 1,390 vs. 51%; 485) were leading, followed by trauma missions (18%; 690 vs. 22%; 464 vs. 39%; 375), aborted missions (3%; 126 vs. 7%; 154 vs. 6%; 56), and dead on arrival (5%; 197 vs. 5%; 106 vs. 4%; 41). Although, the percentage of patients with NACA IV–VI (39% vs. 50%) or patients with GCS ≤8 (18% vs. 34%) was lower in 2004, the absolute number of patients in each categorie was higher than in 1984 (NACA IV–VI: 1,434 vs. 448, p<0.01; GCS: 672 vs. 303, p<0.01).ConclusionsThe results of this study demonstrate, that the percentage of trauma, severely ill/injured or unconscious patients is lower than in previous years. However, the higher absolute numbers of patients demonstrate that the emergency physician now encounters more critically ill/injured, unconscious and trauma patients. It does not seem necessary to question the qualifications for an emergency physician, which have previously been considered essential for the management of acute life-threatening situations.

Invasive Notfalltechniken in der Notfallmedizin

ZusammenfassungDie Thoraxdrainage, intraossäre Punktion und Notfallkoniotomie sind lebensrettende invasive Notfalltechniken. Internationale und nationale Empfehlungen geben dabei klare Vorgaben zur Indikation und Durchführung. Dennoch ist die Anwendung selbst bzw. sind die Situationen, in denen entsprechende Notfalltechniken zur Anwendung kommen, für Notärzte oft stress- und angstbesetzte Ereignisse. Hinweise auf Defizite in der Indikationsstellung und der Anwendung der drei Notfalltechniken finden sich vielfach in der Literatur. Umfragen zeigen, dass sich Notärzte hinsichtlich der invasiven Notfalltechniken häufig durch ihre theoretische Ausbildung und innerklinische Tätigkeit unzureichend auf den Notarztdienst vorbereitet fühlen. Vor diesem Hintergrund haben praxisorientierte und realitätsnahe Ausbildungskonzepte zum Erlernen und Training invasiver Notfalltechniken einen beträchtlichen Wert für den in der Notfallmedizin Tätigen.AbstractThorax drainage, intraosseous puncture and emergency coniotomy (cricothyrotomy) are life-saving invasive emergency techniques. International and national recommendations give clear instructions on indications and implementation. However, the implementation itself and the corresponding situation when emergency techniques are to be used are often fraught with stress and fear for the emergency physician. Advice on deficits in the diagnosis and implementation of the three emergency techniques has been often described in the literature. Questionnaires have shown that the theoretical training and clinical practice is insufficient and often leads emergency physicians to feel unprepared for emergency situations. With this background practice-oriented and reality-related training concepts to learn and practice invasive emergency techniques are of great value to those active in emergency medical services.

Is a 4 days transoesophageal training course sufficient to diagnose shock related pathologies

INTRODUCTION Echocardiography is a useful tool in patients suffering from shock of unknown origin to evaluate cardiac function and volume status in order to decide on further treatment. The aim of the study was to evaluate how well participants could identify function, preload and regional wall motion abnormalities after attending a 4-day transoesophageal echocardiography (TOE) seminar. METHODS In this prospective educational trial, participants of six TOE seminars from 2005 to 2006 were evaluated. On the basis of seven echocardiographic studies, evaluations by participants concerning cardiac function, preload and regional wall motion were analyzed. Moreover, specific causes of undifferentiated hypotension were to be judged in three cases by the participants. RESULTS A total of 115 participants of the TOE seminars from 2005 to 2006 were evaluated. Correct sectional plane was recognized by more than 76% of the participants. Left ventricular function, preload, and regional wall abnormalities were assessed correctly by the participants in 98%, 96%, and 84%, respectively. Moreover, more than 70% of the participants recognized the correct cause of hemodynamic instability. CONCLUSION The results of the investigation show that participants of a 4-day TOE seminar can interpret left ventricular function, preload and regional wall motion abnormalities correctly at a very high rate. TOE seminars seem to be effective in teaching basic theoretical knowledge of TOE.

Stumpfe traumatische Aortenverletzung

Traumatic injury of the aorta can be a fatal complication of blunt thoracic trauma and if it is survived and diagnosed, surgery will be necessary. A prerequisite is a prompt imaging diagnosis of the injury in order to plan an optimal therapeutic procedure for the patient, depending on the severity of the injury. Digital angiography has now been replaced by non-invasive methods, such as computer tomography (CT) or transesophageal echocardiography (TEE). Using TEE it is possible to carry out a staging of the injury and this classification together with the corresponding clinical symptoms determines the therapeutic treatment regime. In many cases a staged treatment is standard procedure. In addition to the establishment of an adequate blood pressure (for prophylaxis of the open rupture), monitoring during the course of treatment may be necessary. The main advantage of TEE is that the examination of these mostly multiple traumatised patients can be carried out at the bedside. This review describes the use of TEE as a diagnostic tool in the early phase and for continuous monitoring of an initially conservative treatment regime.ZusammenfassungDie traumatische Aortenverletzung kann eine deletäre Komplikation des stumpfen Thoraxtraumas sein. Wenn sie überlebt und diagnostiziert wird, ist eine chirurgische Versorgung notwendig. Voraussetzung ist eine zeitnahe bildgebende Diagnostik dieser Verletzung, um je nach Verletzungsschwere ein für den Patienten optimales therapeutisches Vorgehen planen zu können. Die digitale Angiographie wurde mittlerweile von nichtinvasiven Methoden wie der Computertomographie (CT) oder der transösophagealen Echokardiographie (TEE) abgelöst. Mithilfe der TEE ist es möglich, eine Stadieneinteilung dieser Verletzungen durchzuführen. Mit dieser Klassifikation und der dazugehörigen klinischen Symptomatik ergibt sich das therapeutische Handlungsschema. In vielen Fällen ist heute eine Versorgung im Intervall üblich. Neben einer adäquaten Blutdruckeinstellung (zur Prophylaxe der freien Ruptur) sind ggf. Untersuchungen im Verlauf erforderlich. Hier liegt ein großer Vorteil der TEE in der Untersuchung des meistens polytraumatisierten Patienten am Krankenbett. Diese Übersicht beschreibt den Einsatz der TEE als ein diagnostisches Instrument in der frühen Phase und als Mittel der Verlaufsuntersuchungen bei einem primär konservativen Regime.AbstractTraumatic injury of the aorta can be a fatal complication of blunt thoracic trauma and if it is survived and diagnosed, surgery will be necessary. A prerequisite is a prompt imaging diagnosis of the injury in order to plan an optimal therapeutic procedure for the patient, depending on the severity of the injury. Digital angiography has now been replaced by non-invasive methods, such as computer tomography (CT) or transesophageal echocardiography (TEE). Using TEE it is possible to carry out a staging of the injury and this classification together with the corresponding clinical symptoms determines the therapeutic treatment regime. In many cases a staged treatment is standard procedure. In addition to the establishment of an adequate blood pressure (for prophylaxis of the open rupture), monitoring during the course of treatment may be necessary. The main advantage of TEE is that the examination of these mostly multiple traumatised patients can be carried out at the bedside. This review describes the use of TEE as a diagnostic tool in the early phase and for continuous monitoring of an initially conservative treatment regime.

Morphine-induced acute lung injury

A 38-year-old woman who had familial adenomatous polyposis was admitted to the intensive care unit with an episode of severe sepsis 5 days after undergoing a pancreas-preserving duodenectomy. Laparotomy with removal of an intra-abdominal abscess, followed by closed postoperative continuous lavage for 10 days, was performed. During two courses of planned tracheal extubation, the patient developed an acute lung injury, making a reintubation necessary. In both events, the patient received small doses of continuous morphine before the extubation. Morphine may induce the development of an acute lung injury in patients, whereas the exact pathophysiologic and pharmacologic mechanisms remain unclear.

[Blunt traumatic aortic injury: importance of transesophageal echocardiography].

Traumatic injury of the aorta can be a fatal complication of blunt thoracic trauma and if it is survived and diagnosed, surgery will be necessary. A prerequisite is a prompt imaging diagnosis of the injury in order to plan an optimal therapeutic procedure for the patient, depending on the severity of the injury. Digital angiography has now been replaced by non-invasive methods, such as computer tomography (CT) or transesophageal echocardiography (TEE). Using TEE it is possible to carry out a staging of the injury and this classification together with the corresponding clinical symptoms determines the therapeutic treatment regime. In many cases a staged treatment is standard procedure. In addition to the establishment of an adequate blood pressure (for prophylaxis of the open rupture), monitoring during the course of treatment may be necessary. The main advantage of TEE is that the examination of these mostly multiple traumatised patients can be carried out at the bedside. This review describes the use of TEE as a diagnostic tool in the early phase and for continuous monitoring of an initially conservative treatment regime.ZusammenfassungDie traumatische Aortenverletzung kann eine deletäre Komplikation des stumpfen Thoraxtraumas sein. Wenn sie überlebt und diagnostiziert wird, ist eine chirurgische Versorgung notwendig. Voraussetzung ist eine zeitnahe bildgebende Diagnostik dieser Verletzung, um je nach Verletzungsschwere ein für den Patienten optimales therapeutisches Vorgehen planen zu können. Die digitale Angiographie wurde mittlerweile von nichtinvasiven Methoden wie der Computertomographie (CT) oder der transösophagealen Echokardiographie (TEE) abgelöst. Mithilfe der TEE ist es möglich, eine Stadieneinteilung dieser Verletzungen durchzuführen. Mit dieser Klassifikation und der dazugehörigen klinischen Symptomatik ergibt sich das therapeutische Handlungsschema. In vielen Fällen ist heute eine Versorgung im Intervall üblich. Neben einer adäquaten Blutdruckeinstellung (zur Prophylaxe der freien Ruptur) sind ggf. Untersuchungen im Verlauf erforderlich. Hier liegt ein großer Vorteil der TEE in der Untersuchung des meistens polytraumatisierten Patienten am Krankenbett. Diese Übersicht beschreibt den Einsatz der TEE als ein diagnostisches Instrument in der frühen Phase und als Mittel der Verlaufsuntersuchungen bei einem primär konservativen Regime.AbstractTraumatic injury of the aorta can be a fatal complication of blunt thoracic trauma and if it is survived and diagnosed, surgery will be necessary. A prerequisite is a prompt imaging diagnosis of the injury in order to plan an optimal therapeutic procedure for the patient, depending on the severity of the injury. Digital angiography has now been replaced by non-invasive methods, such as computer tomography (CT) or transesophageal echocardiography (TEE). Using TEE it is possible to carry out a staging of the injury and this classification together with the corresponding clinical symptoms determines the therapeutic treatment regime. In many cases a staged treatment is standard procedure. In addition to the establishment of an adequate blood pressure (for prophylaxis of the open rupture), monitoring during the course of treatment may be necessary. The main advantage of TEE is that the examination of these mostly multiple traumatised patients can be carried out at the bedside. This review describes the use of TEE as a diagnostic tool in the early phase and for continuous monitoring of an initially conservative treatment regime.

Prähospitale geburtshilfliche Notfälle in einem bodengebundenen städtischen Notarztsystem

BACKGROUND In the German emergency medical system (EMS) obstetrical emergencies are rarely encountered, but are highly emotional situations for all concerned and form a special challenge for the emergency physician. The aim of this study was to evaluate the incidence, the course and the performance of rescue missions in a ground-based EMS system. METHODS In a retrospective study the prehospital emergency charts concerning obstetrical emergencies over a 5-year period (10/2002-09/2007) were analysed. RESULTS A total of 40 physician-staffed rescue missions with obstetrical emergencies were identified. On average seven rescue missions were performed per year. The majority of cases with 73% of the rescue missions was performed during the night service (16:00-07:00 h). On average the emergency patients (26th-41st week of gestation) were classified by the National Advisory Committee for Aeronautics (NACA) score as NACA III. Of the 40 obstetrical emergencies delivery occurred out of hospital in 18 cases (33rd-41st week of gestation), while the emergency physician was present in only 3 cases during childbirth. In 15 cases prehospital childbirth took place in the domestic environment of the patient, in 2 cases in an ambulance and in 1 case in the medical office of a gynecologist. In 20 cases the pregnant women were transported to hospital while labor had already begun. The emergency physicians on scene applied intravenous access, guided through labor and delivery, and administered tocolysis and in cases of prehospital delivery the emergency physicians also applied oxytocin, cut the umbilical cord and performed primary care of the newborn. CONCLUSIONS Obstetrical emergencies are rare but recurrent in the ground-based EMS. However, prehospital management of women in labor, supervision of spontaneous prehospital delivery and the initial management of a newborn form a challenge for the emergency physician responsible. Consequently, prehospital management of obstetrical emergencies needs intensive consideration during education and training of emergency medical personnel.