Torsten Schröder

Altered cell-mediated immunity and increased postoperative infection rate in long-term alcoholic patients.

Background: Preoperative alteration of T cell–mediated immunity as well as an altered immune response to surgical stress were found in long-term alcoholic patients. The aim of this study was to evaluate perioperative T cell–mediated immune parameters as well as cytokine release from whole blood cells after lipopolysaccharide stimulation and its association with postoperative infections. Methods: Fifty-four patients undergoing elective surgery of the aerodigestive tract were included in this prospective observational study. Long-term alcoholic patients (n = 31) were defined as having a daily ethanol consumption of at least 60 g and fulfilling the Diagnostic and Statistical Manual of Mental Disorders for either alcohol abuse or alcohol dependence. The nonalcoholic patients (n = 23) were defined as drinking less than 60 g ethanol/day. Blood samples to analyze the immune status were obtained on morning before surgery and on the morning of days 1, 3, and 5 after surgery. Results: Basic patient characteristics did not differ between groups. Before surgery, the T helper 1:T helper 2 ratio (Th1: Th2) was significantly lower (P < 0.01), whereas plasma interleukin 1β and lipopolysaccharide-stimulated interleukin 1ra from whole blood cells were increased in long-term alcoholic patients. After surgery, a significant suppression of the cytotoxic lymphocyte ratio (Tc1:Tc2), the interferon γ:interleukin 10 ratio from lipopolysaccharide-stimulated whole blood cells, and a significant increase of plasma interleukin 10 was observed. Long-term alcoholics had more frequent postoperative infections compared with nonalcoholic patients (54%vs. 26%; P = 0.03). Conclusions: T helper cell–mediated immunity was significantly suppressed before surgery and possibly led to inadequate cytotoxic lymphocyte and whole blood cell response in long-term alcoholic patients after surgery. This altered cell-mediated immunity might have accounted for the increased infection rate in long-term alcoholic patients after surgery.

Gender differences in the performance of a computerized version of the alcohol use disorders identification test in subcritically injured patients who are admitted to the emergency department.

OBJECTIVE The Alcohol Use Disorder Identification Test (AUDIT) has been recommended as a screening tool to detect patients who are appropriate candidates for brief, preventive alcohol interventions. Lower AUDIT cutoff scores have been proposed for women; however, the appropriate value remains unknown. The primary purpose of this study was to determine the optimal AUDIT cutpoint for detecting alcohol problems in subcritically injured male and female patients who are treated in the emergency department (ED). An additional purpose of the study was to determine whether computerized screening for alcohol problems is feasible in this setting. METHODS The study was performed in the ED of a large, urban university teaching hospital. During an 8-month period, 1205 male and 722 female injured patients were screened using an interactive computerized lifestyle assessment that included the AUDIT as an embedded component. World Health Organization criteria were used to define alcohol dependence and harmful drinking. World Health Organization criteria for excessive consumption were used to define high-risk drinking. The ability of the AUDIT to classify appropriately male and female patients as having one of these three conditions was the primary outcome measure. RESULTS Criteria for any alcohol use disorder were present in 17.5% of men and 6.8% of women. The overall accuracy of the AUDIT was good to excellent. At a specificity >0.80, sensitivity was 0.75 for men using a cutoff of 8 points and 0.84 for women using a cutoff of 5 points. Eighty-five percent of patients completed computerized screening without the need for additional help. CONCLUSIONS Different AUDIT scoring thresholds for men and women are required to achieve comparable sensitivity and specificity when using the AUDIT to screen injured patients in the ED. Computerized AUDIT administration is feasible and may help to overcome time limitations that may compromise screening in this busy clinical environment.

Enoximone in contrast to dobutamine improves hepatosplanchnic function in fluid-optimized septic shock patients.

ObjectiveTo investigate the impact of dobutamine and enoximone on hepatosplanchnic perfusion and function in fluid-optimized septic patients. DesignProspective, randomized, double-blinded interventional study. SettingIntensive care unit of a university hospital. PatientsForty-eight septic shock patients were examined within 12 hrs after onset of septic shock. Patients were conventionally resuscitated, achieving an optimal pulmonary artery occlusion pressure at which the left ventricular stroke work was on the maximal plateau. Liver blood flow was estimated by venous suprahepatic catheterization using the continuous indocyanine green infusion technique. Microsomal liver function was assessed by the plasma appearance of monoethylglycinexylidide, and release of hepatic tumor necrosis factor-&agr; (TNF-&agr;) was measured to estimate the severity of hepatic ischemia-reperfusion syndrome. InterventionsPatients were randomly treated with dobutamine or enoximone. Within the first 10 hrs after baseline measurements, the dosage was increased until no further increase in the left ventricular stroke work index occurred. Then, positive inotropes were kept constant throughout the study. Measurements and Main Results Measurements were performed at baseline and after 12 and 48 hrs after baseline measurements. Cardiac index, systemic oxygen delivery, systemic oxygen consumption, and liver blood flow increased significantly in both groups during treatment (p < .01) without a significant difference between groups. Fractional liver blood flow (liver blood flow/cardiac index) did not change in the enoximone group and showed a significant but only minor (median, 10%) decrease in the dobutamine group (p < .05 after 12 hrs and p < .01 after 48 hrs vs. baseline). After 12 hrs of enoximone treatment, monoethylglycinexylidide kinetics and hepatosplanchnic oxygen consumption demonstrated a significant increase (p < .05). The release of hepatic TNF-&agr; after 12 hrs of dobutamine treatment was twice as high (p < .05) as during enoximone. ConclusionThe increase in hepatosplanchnic oxygen consumption, together with an increased lignocaine metabolism and decreased release of hepatic TNF-&agr;, indicates improved hepatosplanchnic function and antiinflammatory properties after 12 hrs of enoximone treatment. Therefore, if the inflammatory response should be attenuated in high-risk patients, administration of enoximone in fluid-optimized septic shock patients may be favorable compared with dobutamine.

Screening trauma patients with the alcohol use disorders identification test and biomarkers of alcohol use.

BACKGROUND Alcohol screening and brief interventions have been shown to reduce alcohol-related morbidity in injured patients. Use of self-report questionnaires such as the Alcohol Use Disorder Identification Test (AUDIT) is recommended as the optimum screening method. We hypothesized that the accuracy of screening is enhanced by combined use of the AUDIT and biomarkers of alcohol use in injured patients. METHODS The study was conducted in the emergency department of a large, urban, university hospital. Patients were evaluated with the AUDIT, and blood sampled to determine carbohydrate-deficient transferrin, gamma-glutamyl-transferase, and mean corpuscular volume. Alcohol problems were defined as presence of ICD-10 criteria for dependence or harmful use, or high-risk drinking according to World Health Organization criteria (weekly intake >420 g in males, >280 g in females). Screening accuracy was determined using Receiver Operating Characteristic curves. RESULTS There were 787 males and 446 females in the study. Median age was 33 years. The accuracy of the AUDIT was good to excellent, whereas all biomarkers performed only fairly to poorly in males, and even worse in females. At a specificity >0.80, sensitivity for all biomarkers was <0.43, whereas sensitivity for the AUDIT was 0.76 for males and 0.81 for females. The addition of biomarkers added little additional discriminatory information compared to use of the AUDIT alone. CONCLUSIONS Screening properties of the AUDIT are superior to %CDT, MCV, and GGT for detection of alcohol problems in injured patients and are not clinically significantly enhanced by the use of biomarkers.

Myocardial ischemia and cytokine response are associated with subsequent onset of infections after noncardiac surgery

Postoperative myocardial ischemia (POMI) is prevalent among patients after major noncardiac surgery. Surgery, as well as POMI, may modulate the immune system, potentially worsening patient outcome. We sought to investigate the modulation of soluble interleukin (IL)-6 and IL-10 by POMI and its association with increased postoperative infection rates. Two-hundred-three patients undergoing elective major abdominal, vascular, and orthopedic surgery participated in this prospective observational study. Perioperative management was standardized. Hemodynamic variables were kept within 20% of baseline. POMI was assessed by Holter electrocardiography starting at least 8 h before the induction of anesthesia and continued until 96 h after surgery. Twelve-lead electrocardiograms, cardiac enzymes, and immune variables were obtained at the time of admission to the hospital, before surgery, before the induction of anesthesia, after surgery, at the time of admission to the intensive care unit, and 6, 12, 18, 24, 36, 48, 72, 96, 120, 144, and 168 h after surgery. Infections were diagnosed according to the Centers for Disease Control criteria. The incidence of POMI was 27%, and the majority of cases (76%) occurred within the first 24 h after surgery. IL-6 and IL-10 levels significantly increased during surgery but did not differ between the POMI and Non-POMI groups. However, in the subset of patients who developed severe infections or sepsis (n = 47) a median of 3 days (range, 1–8 days) after surgery, the intraoperative increases of IL-6 and IL-10 in the POMI group were, respectively, 3 and 10 times higher compared with the increase in the Non-POMI group. By using a multifactorial analysis in these patients with severe infections, the type of surgical trauma was associated with an increased IL-6 response, whereas the increase in IL-10 was attributed to POMI. These findings suggest that immediate cytokine responses due to POMI and type of surgery might be relevant for the later onset of severe infections and sepsis.

Anästhesie bei extremer Adipositas

Hintergrund: Etwa 1–2% aller Patienten, die sich einer Anästhesie unterziehen müssen, leiden unter extremer Adipositas (Bodymass-Index > 35 kg/m2). Die perioperative Letalität bei extrem adipösen Patienten ist gegenüber normalgewichtigen Patienten signifikant erhöht und wird bis zu 20% beschrieben. Zu den Komplikationen gehören Intubationsschwierigkeiten (13–20%) und Aspiration. Eine Hypoxie kann während der Narkoseeinleitung trotz Präoxygenierung, bei kritischem Abfall der Sauerstoffsättigung schon nach kurzer Apnoe, und postoperativ, bei häufig (50%) bestehendem Schlafapnoesyndrom, auftreten. Ausbildung von pulmonalen Atelektasen (5%), kardiale Komplikationen bei vorbestehenden Herz-Kreislauf-Erkrankungen sowie ein erhöhtes Risiko für eine Lungenembolie (5–12%) gefährden den adipösen Patienten. Narkoseleitung: Die präoperative Evaluation der wesentlichen Begleiterkrankungen ermöglicht ein individuelles intra- und postoperatives Management. Durch den Einsatz monderner Pharmaka (Desfluran, Sevofluran oder Propofol kombiniert mit Remifentanil) können die Patienten nach einer Operation rasch mobilisiert werden. Angepasstes Monitoring, das routinemäßig aus einer arteriellen Blutdruckmessung und repetitiven Blutgasanalysen bestehen sollte, erhöht die perioperative Sicherheit und ermöglicht das Erkennen von kritischen Situationen schon vor Eintritt von Komplikationen. Postoperative Behandlung: Eine postoperative intensivmedizinische Behandlung adipöser Patienten richtet sich nach der Schwere der Begleiterkrankungen und den operativen Gegebenheiten. Ausschlaggebend für die Aufnahme ist häufig die Einschränkung des pulmonalen Gasaustauschs. Durch eine enge interdisziplinäre Zusammenarbeit ist es möglich, bei extrem adipösen Patienten eine Anästhesie mit vertretbarem Risiko durchzuführen.Background: Approximately 1–2% of all anesthetized patients are morbidly obese (body mass index > 35 kg/m2) compared with lean patients. Morbidly obese patients are at high risk for cardiopulmonary dysfunction. Difficult airway management is reported in 13–20% of obese patients. Hypoxia is often observed due to faster desaturation during induction of anesthesia. After surgery, patients are endangered by a high incidence of obstructive sleep apnea syndrome (50%), pulmonary atelectasis (5%) and acute pulmonary embolism (5–12%). Anesthesia Individualized perioperative management is required based on preoperative history and physical examination. Modern anesthetic drugs (desfluran, sevoflurane or propofol, and remifentanil, respectively) allow rapid recovery and early postoperative mobilization. Adequate monitoring, e. g. by an intraarterial blood pressure monitoring and repetitive blood gas analyses, improves patient safety prior the onset of complications. Postoperative Management: Postoperative admission on an intensive care unit of morbidly obese patients is based upon concomitant diseases and surgical requirements. The main reason for admission is an inadequate pulmonary gas exchange. This interdisciplinary approach will reduce the risk of anesthesia and avoid complications in morbidly obese patients.

Perioperative indocyanine green clearance is predictive for prolonged intensive care unit stay after coronary artery bypass grafting - an observational study

IntroductionDuring cardiac surgery with cardiopulmonary bypass (CPB) haemodilution occurs. Hepatic dysfunction after CPB is a rare, but serious, complication. Clinical data have validated the plasma-disappearance rate of indocyanine green (PDR ICG) as a marker of hepatic function and perfusion. Primary objective of this analysis was to investigate the impact of haemodilutional anaemia on hepatic function and perfusion by the time course of PDR ICG and liver enzymes in elective CABG surgery. Secondary objective was to define predictors of prolonged ICU treatment like decreased PDR ICG after surgery.Methods60 Patients were subjected to normothermic CPB with predefined levels of haemodilution anaemia (haemotacrit (Hct) of 25% versus 20% during CPB). Hepatic function and perfusion was assessed by PDR ICG, plasma levels of aspartate aminotransferase (ASAT) and α-GST. Prolonged ICU treatment was defined as treatment ≥ 48 hours.ResultsLogistic regression analysis showed that all postoperative measurements of PDR ICG (P < 0.01), and the late postoperative ASAT (P < 0.01) measurement were independent risk factors for prolonged ICU treatment. The predictive capacity for prolonged ICU treatment was best of the PDR ICG one hour after admission to the ICU. Furthermore, the time course of PDR ICG as well as ASAT and α-GST did not differ between groups of haemodilutional anaemia.ConclusionsOur study provides evidence that impaired PDR ICG as a marker of hepatic dysfunction and hypoperfusion may be a valid marker of prolonged ICU treatment. Additionally this study provides evidence that haemodilutional anaemia to a Hct of 20% does not impair hepatic function and perfusion.Trial registration[ISRCTN35655335]

Simulation als Möglichkeit zum Training palliativer Notfälle

BACKGROUND Palliative emergencies describe an acute situation in patients with a life-limiting illness. At present defined curricula for prehospital emergency physician training for palliative emergencies are limited. Simulation-based training (SBT) for such palliative emergency situations is an exception both nationally and internationally. AIM This article presents the preparation of recommendations in the training and development of palliative care emergency situations. MATERIAL AND METHODS A selected literature search was performed using PubMed, EMBASE, Medline and the Cochrane database (1990-2013). Reference lists of included articles were checked by two reviewers. Data of the included articles were extracted, evaluated und summarized. In the second phase the participants of two simulated scenarios of palliative emergencies were asked to complete an anonymous 15-item questionnaire. The results of the literature search and the questionnaire-based investigation were compared and recommendations were formulated based on the results. RESULTS Altogether 30 eligible national and international articles were included. Overall, training curricula in palliative emergencies are currently being developed nationally and internationally but are not yet widely integrated into emergency medical training and education. In the second part of the investigation, 25 participants (9 male, 16 female, 20 physicians and 5 nurses) were included in 4 multiprofessional emergency medical simulation training sessions. The most important interests of the participants were the problems for training and further education concerning palliative emergencies described in the national and international literature. CONCLUSION The literature review and the expectations of the participants underlined that the development and characteristics of palliative emergencies will become increasingly more important in outpatient emergency medicine. All participants considered palliative care to be very important concerning the competency for end-of-life decisions in palliative patients. For this reason, special curricula and simulation for dealing with palliative care patients and special treatment decisions in emergency situations seem to be necessary.

Simulation in der Intensivmedizin

Einen besonders komplexen Bereich der Medizin umfasst die Intensivmedizin, bei der kritisch kranke Menschen mit einem hohen medizinischen, personellen und technischen Aufwand therapiert werden. Unterschiedlichste Krankheitsbilder begegnen einem in diesem Feld: Von der Versorgung polytraumatisierter Patienten uber die schwere Sepsis bis hin zu einer Vielzahl von unterschiedlichsten Organversagen, welche dann im sog. Multiorganversagen gipfeln. Die zeitlichen Verlaufe konnen hoch akut uber Minuten (z. B. Herzversagen, Trauma), aber auch langsam progredient uber Stunden bis Tage verlaufen (z. B. Nierenversagen). Viele anasthesiologische und notfallmedizinische Fertigkeiten bilden dabei auch die Basis fur Behandlungsstrategien der Intensivmedizin (z. B. Beatmung, Flussigkeits- und Volumenersatz, hamodynamische Stabilisierung). Viele Entscheidungen mussen haufig interdisziplinar und multiprofessionell gefallt und zum Teil mit Angehoren besprochen werden.

Pregnancy outcome in patients with complex pulmonary atresia: case report and review of the literature

Pulmonary atresia, a rare and complex congenital heart disease, is characterized by the absence of the central pulmonary artery and by the presence of a ventricular septal defect and aortopulmonary collaterals. Pregnancy reports concerning maternal and offspring outcome after palliative operation or repaired pulmonary atresia are sparse. We report here on the outcome of pregnancy in a woman, aged 36, with complex pulmonary atresia in whom palliative operation had been performed at the age of 23. We review the medical literature on pregnancy course as well as maternal and foetal outcome in cases involving this maternal congenital heart disease.