Rainer Meierhenrich

Incidence and prognostic impact of new-onset atrial fibrillation in patients with septic shock: a prospective observational study

IntroductionSince data regarding new-onset atrial fibrillation (AF) in septic shock patients are scarce, the purpose of the present study was to evaluate the incidence and prognostic impact of new-onset AF in this patient group.MethodsWe prospectively studied all patients with new-onset AF and all patients suffering from septic shock in a non-cardiac surgical intensive care unit (ICU) during a 13 month period.ResultsDuring the study period, 687 patients were admitted to the ICU, of which 58 patients were excluded from further analysis due to pre-existing chronic or intermittent AF. In 49 out of the remaining 629 patients (7.8%) new-onset AF occurred and 50 out of the 629 patients suffered from septic shock. 23 out of the 50 patients with septic shock (46%) developed new-onset AF. There was a steady, significant increase in C-reactive protein (CRP) levels before onset of AF in septic shock patients. ICU mortality in septic shock patients with new-onset AF was 10/23 (44%) compared with 6/27 (22%) in septic shock patients with maintained sinus rhythm (SR) (P = 0.14). During a 2-year follow-up there was a trend towards an increased mortality in septic shock patients with new-onset AF, but the difference did not reach statistical significance (P = 0.075). The median length of ICU stay among surviving patients was longer in patients with new-onset AF compared to those with maintained SR (30 versus 17 days, P = 0.017). The success rate to restore SR was 86%. Failure to restore SR was associated with increased ICU mortality (71.4% versus 21.4%, P = 0.015).ConclusionsAF is a common complication in septic shock patients and is associated with an increased length of ICU stay among surviving patients. The increase in CRP levels before onset of AF may support the hypothesis that systemic inflammation is an important trigger for AF.

Reduction of postoperative pulmonary complications after lung surgery using a fast track clinical pathway

BACKGROUND Fast track programs, multimodal therapy strategies, have been introduced in many surgical fields to minimize postoperative morbidity and mortality. In terms of lung resections no randomized controlled trials exist to evaluate such patient care programs. METHODS In a prospective, randomized controlled pilot study a conservative and fast track treatment regimen in patients undergoing lung resections was compared. Main differences between the two groups consisted in preoperative fasting (6h vs 2h) and analgesia (patient controlled analgesia vs patient controlled epidural analgesia). Study endpoints were pulmonary complications (pneumonia, atelectasis, prolonged air leak), overall morbidity and mortality. Analysis was performed in an intention to treat. RESULTS Both study groups were similar in terms of age, sex, preoperative forced expiratory volume in one second (FEV(1)), American Society of Anesthesiologists score and operations performed. The rate of postoperative pulmonary complications was 35% in the conservative and 6.6% in the fast track group (p=0.009). A subgroup of patients with reduced preoperative FEV(1) (<75% of predicted value) experienced less pulmonary complications in the fast track group (55% vs 7%, p=0.023). Overall morbidity was not significantly different (46% vs 26%, p=0.172), mortality was comparable in both groups (4% vs 3%). CONCLUSION We evaluated an optimized patient care program for patients undergoing lung resections in a prospective randomized pilot study. Using this fast track clinical pathway the rate of pulmonary complications could be significantly decreased as compared to a conservative treatment regimen; our results support the implementation of an optimized perioperative treatment in lung surgery in order to reduce pulmonary complications after major lung surgery.

Prolonged Classical NF-κB Activation Prevents Autophagy upon E. coli Stimulation In Vitro: A Potential Resolving Mechanism of Inflammation

Activation of NF-κB is known to prevent apoptosis but may also act as proapoptotic factor in order to eliminate inflammatory cells. Here, we show that classical NF-κB activation in RAW 264.7 and bone marrow-derived macrophages upon short E. coli coculture is necessary to promote cell death at late time points. At 48 hours subsequent to short-term, E. coli challenge increased survival of NF-κB-suppressed macrophages was associated with pattern of autophagy whereas macrophages with normal NF-κB signalling die. Cell death of normal macrophages was indicated by preceding downregulation of autophagy associated genes atg5 and beclin1. Restimulation of macrophages with LPS at 48 hours after E. coli treatment results in augmented proinflammatory cytokine production in NF-κB-suppressed macrophages compared to control cells. We thus demonstrate that classical NF-κB activation inhibits autophagy and promotes delayed programmed cell death. This mechanism is likely to prevent the recovery of inflammatory cells and thus contributes to the resolution of inflammation.

Electrocardiographic exercise stress testing for cardiac risk assessment in patients undergoing noncardiac surgery.

BackgroundThe value of exercise electrocardiography in the prediction of perioperative cardiac risk has yet to be defined. This study was performed to determine the predictive value of exercise electrocardiography as compared with clinical parameters and resting electrocardiography. MethodsA total of 204 patients at intermediate risk for cardiac complications prospectively underwent exercise electrocardiography before noncardiac surgery. Of these, 185 were included in the final evaluation. All patients underwent follow-up evaluation postoperatively by Holter monitoring for 2 days, daily 12-lead electrocardiogram, and creatine kinase, creatine kinase MB, and troponin-T measurements for 5 days. Cardiac events were defined as cardiac death, myocardial infarction, minor myocardial cell injury, unstable angina pectoris, congestive heart failure, and ventricular tachyarrhythmia. Potential risk factors for an adverse event were identified by univariate and multivariate logistic regression analysis. ResultsPerioperative cardiac events were observed in 16 patients. There were 6 cases of myocardial infarction and 10 cases of myocardial cell injury. The multivariate correlates of adverse cardiac events were definite coronary artery disease (odds ratio, 8.8; 95% confidence interval [CI], 1.1–73.1;P = 0.04), major surgery (odds ratio, 4.7; 95% CI, 1.3–16.3;P = 0.02), reduced left ventricular performance (odds ratio, 2.0; 95% CI, 1.1–3.8;P = 0.03), and ST-segment depression of 0.1 mV or more in the exercise electrocardiogram (odds ratio, 5.2; 95% CI, 1.5–18.5;P = 0.01). A combination of clinical variables and exercise electrocardiography improved preoperative risk stratification. ConclusionsThis prospective study shows that a ST-segment depression of 0.1 mV or more in the exercise electrocardio-gram is an independent predictor of perioperative cardiac complications.

The effects of intraabdominally insufflated carbon dioxide on hepatic blood flow during laparoscopic surgery assessed by transesophageal echocardiography.

Conflicting results have been published about the effects of carbon dioxide (CO2) pneumoperitoneum on splanchnic and liver perfusion. Several experimental studies described a pressure-related reduction in hepatic blood flow, whereas other investigators reported an increase as long as the intraabdominal pressure (IAP) remained less than 16 mm Hg. Our goal in the present study was to investigate the effects of insufflated CO2 on hepatic blood flow during laparoscopic surgery in healthy adults. Blood flow in the right and middle hepatic veins was assessed in 24 patients undergoing laparoscopic surgery by use of transesophageal Doppler echocardiography. Hepatic venous blood flow was recorded before and after 5, 10, 20, 30, and 40 min of pneumoperitoneum, as well as 1 and 5 min after deflation. Twelve patients undergoing conventional hernia repair served as the control group. The induction of pneumoperitoneum produced a significant increase in blood flow of the right and middle hepatic veins. Five minutes after insufflation of CO2 the median right hepatic blood flow index increased from 196 mL/min/m2 (95% confidence interval (CI), 140–261 mL/min/m2) to 392 mL/min/m2 (CI, 263–551 mL/min/m2) (P < 0.05) and persisted during maintenance of pneumoperitoneum. In the middle hepatic vein the blood flow index increased from 105 mL/min/m2 (CI, 71–136 mL/min/m2) to 159 mL/min/m2 (CI, 103–236 mL/min/m2) 20 min after insufflation of CO2. After deflation blood flow returned to baseline values in both hepatic veins. Conversely, in the control group hepatic blood flow remained unchanged over the entire study period. We conclude that induction of CO2 pneumoperitoneum with an IAP of 12 mm Hg is associated with an increase in hepatic perfusion in healthy adults.

The effects of thoracic epidural anesthesia on hepatic blood flow in patients under general anesthesia.

BACKGROUND: Hepatic hypoperfusion is regarded as an important factor in the pathophysiology of perioperative liver injury. Although epidural anesthesia (EDA) is a widely used technique, no data are available about the effects on hepatic blood flow of thoracic EDA with blockade restricted to thoracic segments in humans. METHODS: In 20 patients under general anesthesia, we assessed hepatic blood flow index in the right and middle hepatic vein by use of multiplane transesophageal echocardiography before and after induction of EDA. The epidural catheter was inserted at TH7-9, and mepivacaine 1% with a median (range) dose of 10 (8–16) mL was injected. Norepinephrine (NE) was continuously administered to patients who demonstrated a decrease in mean arterial blood pressure below 60 mm Hg after induction of EDA (EDA-NE group). The other patients did not receive any catecholamine during the study period (EDA group). A further 10 patients without EDA served as controls (control group). RESULTS: In five patients, administration of NE was necessary to avoid a decrease in mean arterial blood pressure below 60 mm Hg. Thus, the EDA-NE group consisted of five patients and the EDA group of 15. In the EDA group, EDA was associated with a median decrease in hepatic blood flow index of 24% in both hepatic veins (P < 0.01). In the EDA-NE group, all five patients showed a decrease in the blood flow index of the right (median decrease 39 [11–45] %) and middle hepatic vein (median decrease 32 [7–49] %). Patients in the control group showed a constant blood flow index in both hepatic veins. Reduction in blood flow index in the EDA group and the EDA-NE group was significant in comparison with the control group (P < 0.05). In contrast to hepatic blood flow, cardiac output was not affected by EDA. CONCLUSIONS: We conclude that, in humans, thoracic EDA is associated with a decrease in hepatic blood flow. Thoracic EDA combined with continuous infusion of NE seems to result in a further decrease in hepatic blood flow.

Transesophageal Echocardiographic Guidance of Thoracic Aortic Stent-Graft Implantation

Purpose: To evaluate the efficacy of intraoperative transesophageal echocardiography (TEE) as an adjunctive measure in guiding the implantation of endoluminal stent-grafts in the thoracic aorta. Methods: TEE was used in 21 of 30 patients (27 men; median age 70 years; range 19–77) undergoing implantation of Excluder or Talent stent-grafts for management of 11 type B aortic dissections, 7 thoracic aortic aneurysms, 2 traumatic thoracic aortic ruptures, and an aortic coarctation. We evaluated the ability of TEE to provide evidence of (1) correct placement of the guidewire within the true lumen, (2) reduction in blood flow in the false lumen following stent deployment, and (3) early complications. Results: Definite identification of the true lumen and a reliable evaluation of the position of the stent-graft guidewire during advancement were possible in all patients. Reduction of blood flow within the false lumen following deployment of the stent-graft was visualized in >70% of patients with aortic dissection. In the patient with aortic coarctation, TEE recognized the acute onset of aortic dissection following stent dilation, which resulted in immediate management with an additional stent. Conclusions: The intraoperative use of TEE in the implantation of stent-grafts in the thoracic aorta is not significantly invasive and is easily employed. It permits excellent evaluation of the correct placement of the stent guidewire and, in patients with aortic dissection, intraoperatively visualizes effective blood flow reduction in the false lumen following stent-graft deployment. Its ability to recognize early complications may indicate the need for additional maneuvers during the surgical procedure.

Resolution of ST-segment elevation in acute myocardial infarction--early prognostic significance after thrombolytic therapy. Results from the COBALT trial

In acute myocardial infarction, early identification of patients at a high mortality risk is important for planning further therapeutic strategies. Previous studies have demonstrated that the extent of carly resolution of ST-segment elevation may represent a simple, quick and noninvasive assessment to identify high risk groups of patients.In a subgroup of the COBALT Study population (Continuous Infusion vs Double Bolus Administration of Alteplase), ST-segment elevation was measured before and 90 to 120 minutes after treatment with alteplase. The subgroup of n=1,760 patients was not different from the total COBALT population of n=7169 patients regarding most clinical parameters except Killip Class before treatment. However, the overall 30-day mortality differed significantly between the main study and the substudy (7.76% vs 3.52%; p < 0.001).Three groups of ST-segment resolution were defined: 1. complete resolution (resolution ≥ 70%; 762 patients), 2. partial resolution (< 70% and > 30%; 491 patients), 3. no resolution (< 30%; 507 patients). Mortality rate at 30 days for complete, partial and no resolution of ST-segment elevation was 1.31%, 4.28% and 6.11%, respectively (p < 0.001). While this significant correlation between the extent of ST-segment resolution and mortality could be observed for inferior acute myocardial infarction, it could not be found in patients with anterior acute myocardial infarction. This in part may be due to a selection bias that leads to an extremely divergent mortality rate of anterior acute myocardial infarction in the main study and the substudy (10.1% vs 3.94%; p<0.0001).Despite this limitation, resolution of ST-segment elevation in acute myocardial infarction after thrombolytic therapy allows to identify patients at a high mortality risk and may help to select patients for early invasive procedures such as PTCA. Patients with complete ST-segment resolution showed a particularly low mortality rate, irrespective of the alteplase regimen used (front-loaded alteplase vs double bolus alteplase).ZusammenfassungDie Standardtherapie des akuten Myokardinfarkts ist die Gabe von Thrombolytika oder die akute perkutane transluminale Koronarangioplastie (PTCA). Beide Verfahren haben die schnelle Wiedereröffnung des infarktverursachenden Koronargefäßes zum Ziel. Nur die frühe Wiederherstellung eines nicht kompromittierten Blutflusses im Koronargefäß führt zu einer Verkleinerung der Infarktgröße und einer Verbesserung der Prognose. Im Falle der thrombolytischen Behandlung ist eine rasche nichtinvasive Identifizierung einer erfolgreichen Wiedereröffnung des Koronargefäßes wünschenswert, um im Falle einer fehlenden Reperfusion frühzeitig die Akutkoronarangiographie und PTCA zu planen. Durch mehrere Studien ist die Rückbildung der ST-Segment-Hebung nach Thrombolyse als prädiktiver Mortalitätsparameter herausgearbeitet worden. Die vorliegende Arbeit diente dazu, anhand einer Subgruppe der COBALT-Studie (Continuous Infusion vs. Double Bolus Administration of Alteplase) den Prädiktor ST-Strecken-Rückbildung im EKG 90 bis 120 Minuten nach Therapie mit Alteplase im Vergleich zum Ausgangs-EKG zu untersuchen. Hierzu wurde die ST-Strecken-Hebung vor und 90 bis 120 Minuten nach Behandlung mit Alteplase verglichen. Die Subgruppe von n=1 760 Patienten unterschied sich nach klinischen Kriterien nicht von der COBALT-Gesamtpopulation von n=7 169 Patienten, mit der Ausnahme der Killip-Klasse von Behandlung (Tabelle 1). Trotz der Vergleichbarkeit klinischer Charakteristika ergab sich eine signifikante Differenz in der 30-Tage-Sterblichkeit zwischen der Gesamtstudie und der EKG-Substudie (7,76% vs. 3,52%; p < 0,001).Es wurden drei Gruppen der Rückbildung der ST-Strecken-Hebung definiert: 1. komplette Rückbildung (Rückbildung > 70%; n=762 Patienten), 2. partielle Rückbildung (<70% and > 30%; n=491 Patienten), 3. keine Rückbildung (<30%; n=507 Patienten; Tabelle 2). Die 30-Tage-Sterblichkeitsrate betrug in der Gruppe der kompletten, der partiellen und der fehlenden ST-Rückbildung 1,31%, 4,28% und 6,11% (p < 0,001; Abbildung 1). Während diese signifikante Assoziation zwischen dem Ausmaß der ST-Strecken-Rückbildung auch in der Untergruppe von Patienten mit inferiorem Myokardinfarkt zu beobachten war, konnte bei Patienten mit anteriorem Myokardinfarkt kein signifikanter Unterschied in der Mortalität zwischen partieller und fehlender ST-Strecken-Rückbildung gefunden werden (Abbildung 2). Dieses kann zumindest teilweise auf eine auffallend divergierende Mortalität des akuten Vorderwandinfarkts in der Hauptstudie und der Substudie zurückgeführt werden (10,1% vs. 3,94%; p < 0,0001). Es wird vermutet, daß die besonders niedrige Mortalität in der Substudie die Ausbildung von signifikanten Unterschieden der Untergruppen unmöglich macht.Trotz dieser Limitation der vorliegenden Studie bestätigte sich das Ausmaß der ST-Strecken-Rückbildung als Prädiktor der 30-Tage-Mortalität bei Thrombolysetherapie des akuten Myokardinfarkts. Somit kann in Übereinstimmung mit früheren Studien (Tabelle 4, Abbildungen 4 und 5) das Ausmaß der ST-Strecken-Rückbildung als nichtinvasiver Parameter genutzt werden, mit dem eine Auswahl der Patienten für eine Akut-PTCA oder erneute Lyse getroffen werden kann. Patienten mit kompletter Rückbildung der ST-Strecken-Hebung nach thrombolytischer Therapie zeigen eine besonders niedrige Mortalitätsrate, unabhängig vom verwendeten Alteplase-Regime (“front-loaded” Alteplase-Infusion oder Doppelbolus Alteplase; Abbildung 3).

Perioperative transcutaneous pacemaker in patients with chronic bifascicular block or left bundle branch block and additional first-degree atrioventricular block

Background: Complete heart block is dreaded perioperatively in patients with chronic bifascicular or left bundle branch block (LBBB) and additional first‐degree A‐V block. Our aim was to investigate the necessity as well as the efficacy and safety of transcutaneous pacing in the perioperative setting.

Therapie bradykarder und tachykarder Herzrhythmusstörungen in der Notfallmedizin

ZusammenfassungDie Diagnose und adäquate Therapie von Herzrhythmusstörrungen in der Notfallmedizin sind von grundlegender Bedeutung. Herzrhythmusstörungen und insbesondere ventrikuläre Tachykardien gelten als wichtigste Ursache für den plötzlichen Herztod. Herzrhythmusstörungen sind präklinisch nur dann zwingend behandlungsbedürftig, wenn sie zur klinischen Instabilität führen oder ein hohes Potenzial der Progredienz in eine lebensbedrohliche Rhythmusstörung haben. So sind bradykarde Rhythmusstörungen selten interventionsbedürftig. Während supraventrikuläre Tachykardien von Herzgesunden zumeist gut toleriert werden, können sie beim kardial Vorerkrankten häufig eine kritische Instabilität verursachen, welche bereits eine präklinische Therapie erfordert. Ventrikuläre Tachykardien benötigen zwingend das notärztliche Eingreifen. Sie entstehen meist auf dem Boden gravierender kardialer Vorerkrankungen und sind häufig mit kritischen Perfusionszuständen assoziiert. Damit steigt das Risiko für den Übergang in Kammerflimmern weiter. Die Indikation für einen medikamentösen Therapieversuch oder eine frühzeitige elektrische Therapie sollte bei allen Rhythmusstörungen immer in Abhängigkeit von der Kreislaufstabilität und dem klinischen Gesamtzustand des Patienten gestellt werden.AbstractDiagnosis and adequate therapy of cardiac arrhythmias are of essential significance in emergency medicine. Cardiac arrhythmias and especially ventricular tachycardia are considered to be key triggers for sudden cardiac death. Preclinical therapy for cardiac arrhythmias is only mandatory in the presence of clinical instability or a high potential for progression to life-threatening arrhythmias. Therefore bradycardia rarely needs intervention outside the clinic. While supraventricular tachycardia is usually well tolerated by the healthy patient, it commonly causes vital instability in patients with a cardiac history needing preclinical therapy. In general, ventricular tachycardia needs preclinical intervention. Usually it is caused by preexisting severe cardiac disease and is associated with critically imbalanced perfusion. Therefore it bears a high risk of progression to ventricular fibrillation. The decision to initiate drug therapy versus early cardioversion/defibrillation should depend on the cardiovascular stability and clinical condition of the patient.