Joachim Wilhelm

Specific aspects in septic patients: initial phase in the emergency department, age, sex and post-ICU-care.

This article deals with specific aspects of the patient with sepsis and his treatment. With adequate therapy (antibiotics started within the first hour, early goal-directed therapy) initiated as early as possible, the patient with community-aquired severe sepsis in the emergency department has a considerable better chance to survive than the patient with prolonged severe sepsis in the ICU. The average age of patients with severe sepsis and septic shock treated at the ICU is rising, with consequences like oligosymptomatic presentation, altered pharmakokinetics according to older-age-induced reduced organ functions and prolonged stay at the ICU due to comorbidity. Due to sexual dimorphisms of the immune system, women have a better prognosis in sepsis than men. In an animal sepsis model activation of the estrogen receptor beta improves prognosis. Within six months after having survived severe sepsis, morbidity and mortality is still increased. Taking care for the patient in a post-ICU outpatient department during this time will help to recognize these problems and to effectively treat the patient as soon as possible.

Non-compaction cardiomyopathy with diffuse left coronary artery fistulae as a rare cause of congestive heart failure.

A 46-year-old woman was admitted to hospital due to dyspnoea. Chest X-ray, serological parameters, and spirometry ruled out pulmonary reasons or infection as its cause. Transthoracic echocardiography revealed a moderately impaired left ventricular (LV) contractility (ejection fraction 42% calculated according to Simpsons rule); there were no relevant valvular pathologies. In the …

Atypical course of a persistent left superior vena cava through the left atrium

A 20-year-old man presented at the emergency department because of presyncope. Physical examination revealed a cardiac murmur located at the second left intercostal space, and therefore, a transthoracic echocardiography (TTE) was performed. A tunnel-like structure was detected at the dorsal wall of the left atrium (LA) superior to the posterior mitral valve leaflet ( Panel A : conventional …

Spezielle Aspekte bei Sepsispatienten

This article deals with specific aspects of the patient with sepsis and his treatment. With adequate therapy (antibiotics started within the first hour, early goal-directed therapy) initiated as early as possible, the patient with community-aquired severe sepsis in the emergency department has a considerable better chance to survive than the patient with prolonged severe sepsis in the ICU. The average age of patients with severe sepsis and septic shock treated at the ICU is rising, with consequences like oligosymptomatic presentation, altered pharmakokinetics according to older-age-induced reduced organ functions and prolonged stay at the ICU due to comorbidity. Due to sexual dimorphisms of the immune system, women have a better prognosis in sepsis than men. In an animal sepsis model activation of the estrogen receptor beta improves prognosis. Within six months after having survived severe sepsis, morbidity and mortality is still increased. Taking care for the patient in a post-ICU outpatient department during this time will help to recognize these problems and to effectively treat the patient as soon as possible.

Wire- and needle potentials facilitating transseptal puncture

BACKGROUND Transseptal puncture for left heart interventions became a routine procedure guided by fluoroscopy and echocardiography. The use of intracardiac potentials derived from the sheath-transseptal-needle/guidewire-combination may provide helpful information to increase safety of this procedure. METHODS AND RESULTS We recorded the intracardiac potentials from the sheath-transseptal-needle/guidewire-combination during the transseptal puncture procedure in 31 consecutive patients (mean age 67.2±8.2years; 21 in sinus rhythm, 10 in atrial fibrillation) designated for ablation of atrial fibrillation by the Cryo-balloon ® technique (Medtronic, Minnesota, USA). The EP-Navigator ® 3-D-image integration tool (Philips Healthcare, Hamburg, Germany) was used for visualization of the device position in relation to the cardiac structures. Typical and reproducible potentials could be derived in all patients for the different device localizations at transseptal puncture procedure. Especially the transition from the muscular interatrial septum into the fossa ovalis could be easily depicted by the changes of both morphology and magnitude of the atrial signal (6.1±2.3mV in sinus rhythm [SR]/3.5±0.9mV in atrial fibrillation [AF] at the muscular interatrial septum and 0.5±0.2mV in SR/0.5±0.1mV in AF in the fossa ovalis). CONCLUSIONS The crucial steps of a transseptal procedure can be verified by typical changes (morphology and amplitude) of the intracardiac signals derived from the sheath-transseptal-needle/guidewire-combination in patients with sinus rhythm as well as in atrial fibrillation.

Mikrozirkulationsstörung, zytopathische Hypoxie und septische Kardiomyopathie

Der septische Schock ist mehr als nur ein Kreislaufschock der grosen Gefase! Die Mikrozirkulationsstorung mit Stase senkt die Prognose und ist derzeit keiner gezielten Therapie zugangig. Die therapierefraktare „zytopathische Hypoxie“ tragt wesentlich zur Energieverarmung der Gewebe bei. Die potenziell reversible septische Kardiomyopathie wird wesentlich durch die diastolische Dysfunktion gepragt. Sie ist am besten mit dem nachlastbezogenen kardialen Herzzeitvolumen („afterload-related cardiac performance“, ACP) zu quantifizieren; die Schwere korreliert mit der Letalitat. Die kardiale autonome Dysfunktion manifestiert sich als Herzfrequenzstarre und inadaquat hohe Herzfrequenz, teils erklart durch die Endotoxin/Schrittmacherkanal(If)-Interaktion. Die Therapie folgt der Standardtherapie des septischen Schocks, in Erprobung sind der Kalziumsensitizer Levosimendan, der kurzwirksame β-Blocker Esmolol (Senkung der inadaquat hohen Herzfrequenz) und der Schrittmacherkanalinhibitor Ivabradin.

In der Notaufnahme

Bei ambulant erworbener, haufig pneumogener Sepsis in der Notaufnahme (Letalitat 10%) fehlt noch der „warme, hyperzirkulatorische Schock“ des flussigkeitstherapierten, beatmeten Sepsispatienten auf der Intensivstation; vielmehr imponiert noch der „kalte, hypozirkulatorische Schock“, mit Hypo- bis Normotonie, Tachypnoe, Exsikkose, Fieber, Schuttelfrost, aber auch Hypothermie, sowie Unruhe, Verwirrtheit, Somnolenz oder Delir („septische Enzephalopathie“). Das Procalcitonin (PCT) ist in dieser Fruhphase der beste Sepsisbiomarker. Die septische Kardiomyopathie – Herzfunktionseinschrankung auf 80% der Norm, nachlastbezogenes HZV („afterload-related cardiac performance“; ACP ≤80% – zeigt eine ungunstige Prognose an.

Herzinsuffizienz — Diagnostik und Therapie in der Praxis

ZusammenfassungDie Herzinsuffizienz ist in Ländern westlicher Prägung eine der bedeutendsten Volkskrankheiten. Zu den Ursachen gehören Bluthochdruck, koronare Herzkrankheit und Herzinfarkt, Diabetes mellitus sowie Nikotin- und Alkoholmissbrauch. Aber auch virale Infekte, Kardiomyopathien und Herzrhythmusstörungen können die Pumpfunktion des Herzens so schwächen, dass die Versorgung des Körpers mit sauerstoffreichem Blut nicht mehr gewährleistet ist. Erfahren Sie hier, wie man die Herzinsuffizienz diagnostiziert und was man dagegen tun kann.

Selective decontamination of the digestive tract and oropharynx: new findings for an old approach still under discussion

Evaluation of: De Smet ANGA, Kluytmans JAJW, Cooper BS et al. Decontamination of the digestive tract and oropharynx in ICU patients. N. Engl. J. Med. 360(1), 20–31 (2009). One of the most severe complications that can develop during treatment at an intensive-care unit is nosocomial infections, especially ventilator-associated pneumonia. The fact that these infections are mainly caused by contamination of pathogens from the digestive and oropharyngeal tracts prompted the idea of selectively decontaminating these two organ systems. Although many reports have been published about reducing the prevalence of ventilator-associated pneumonia and, most importantly, mortality by selective decontamination of the digestive and oropharyngeal tract, there are still many open questions. Furthermore, prophylactic decontamination of these two organ systems is not recommended in international guidelines. This article discusses a recently published study involving more than 5000 patients and illuminates the results in the context of other recent findings concerning this topic.

Spezielle Aspekte bei Sepsispatienten@@@Specific aspects in septic patients: initial phase in the emergency department, age, sex and post-ICU-care: Initiale Phase auf der Notaufnahme, Lebensalter, Geschlecht, Postintensivphase

This article deals with specific aspects of the patient with sepsis and his treatment. With adequate therapy (antibiotics started within the first hour, early goal-directed therapy) initiated as early as possible, the patient with community-aquired severe sepsis in the emergency department has a considerable better chance to survive than the patient with prolonged severe sepsis in the ICU. The average age of patients with severe sepsis and septic shock treated at the ICU is rising, with consequences like oligosymptomatic presentation, altered pharmakokinetics according to older-age-induced reduced organ functions and prolonged stay at the ICU due to comorbidity. Due to sexual dimorphisms of the immune system, women have a better prognosis in sepsis than men. In an animal sepsis model activation of the estrogen receptor beta improves prognosis. Within six months after having survived severe sepsis, morbidity and mortality is still increased. Taking care for the patient in a post-ICU outpatient department during this time will help to recognize these problems and to effectively treat the patient as soon as possible.