Wolfgang Dierschke

Supraglottische Atemwegssicherung und intraossärer Zugang in der Behandlung von Patienten nach außerklinischem Herz-Kreislauf-Stillstand: Verwenden wir das falsche Hilfsmittel zu oft?

INTRODUCTION Only a little is known about the frequency of use of supraglottic airway devices (SADs) and intraosseous (IO) access in patients who have had out-of-hospital cardiac arrest (OHCA). MATERIALS AND METHODS We analyzed data from all patients who had had OHCA admitted to our hospital between 1 January 2008 and 31 December 2017. RESULTS A total of 135 (33.8%) patients who had had OHCA were admitted with a SAD, 223 (55.8%) with an endotracheal tube, 3 (0.8%) with mask ventilation, and 32 (8.0%) breathed spontaneously on admission to hospital. Three hundred and twenty-eight patients (82.0%) were admitted with a peripheral intravenous line, one (0.3%) with a central venous catheter, one (0.3%) with a port catheter, and 32 (8.0%) with IO access. CONCLUSIONS Irrespective of an increasing number of studies that raise the question whether the airway management of patients who have had OHCA using an SGA might be inferior to that with endotracheal tubes, approximately one third of all patients who have had OHCA were admitted with an SAD in this study. On the other hand, IO access is significantly less frequently used, despite fewer critical study results overall.

Erweiterung einer venoarteriellen (VA) ECMO auf eine venovenoarterielle (VVA) ECMO bei schwerem Harlekinsyndrom

ZusammenfassungEs wird über den Fall einer 34-jährigen Patientin berichtet, die nach außerklinischer Reanimation bei therapierefraktärem, kardiogenem Schock im Rahmen einer Myokarditis zunächst mit einer venoarteriellen (VA) extrakorporalen Membranoxygenierung (ECMO) stabilisiert wird. Im Verlauf entwickelt die Patientin bei schwerem Lungenversagen die typischen Befunde des sogenannten Harlekinsyndroms mit unzureichender Sauerstoffversorgung der oberen Körperhälfte. Als schnelle und effektive Lösung findet zur Verbesserung des Sauerstoffangebots von Lungen, Herz und Kopf die Erweiterung auf eine venovenoarterielle (VVA) ECMO statt. Nach Besserung der Symptomatik und weiterer Stabilisierung wird die Patientin komplikationslos in ein kardiochirurgisches Zentrum verlegt.AbstractWe report the case of a 34-year-old female patients admitted to our department of cardiology after out of hospital cardiac arrest. Due to severe therapy resistant cardiogenic shock, a peripheral veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) was implanted. With the occurrence of severe acute respiratory distress syndrome (ARDS) the patient developed the typical symptoms of the so-called harlequin syndrome with insufficient oxygenation of the upper body. The ECMO was converted to veno-veno-arterial (VVA) ECMO for rapid and effective improvement of the pulmonary, coronary and cerebral oxygen supply. After improvement of the symptoms and further stabilization the patient could be transferred to a cardiac surgery clinic without complications.

Organspende bei einer 50‑jährigen Patientin mit Trisomie 21

Aktuell stehen bundesweit mehr als 10.000 Patienten auf der Warteliste für ein Spenderorgan. Lässt man die Lebendspenden unberücksichtigt, so wurden zwischen dem 01.01.2017 und dem 31.05.2017 nur 677 Organe gespendet [1]. Somit besteht auch bei im Vergleich zum Vorjahr steigenden Zahlen an Organspendern (2015: 242, 2016: 209, bis Mitte 2017: 212) [1] weiterhin ein deutlicher Organmangel. Es ist daher eine wichtige ärztliche Aufgabe, potenzielle Organspender zu detektieren. Bei den umfangreichen juristischen und medizinischen Maßnahmen erfolgt eine Unterstützung durch die DSO (Deutsche Stiftung Organtransplantation). Auch Patientenmit Vorerkrankungen sollten nicht ohne Rücksprache als nicht geeignet klassifiziert werden. Die Trisomie 21 ist eine Erberkrankung,welche indenmeistenFällendurch eine freie Trisomie 21 entsteht. In selteneren Fällen entsteht sie durch Translokation,Mosaik-Trisomie oder sehr selten durch eine partielle Trisomie. Die Inzidenz der Erkrankung liegt in Abhängigkeit desAlters derMutter inDeutschland bei 1:800 bis 1:500 Geburten. Mit zunehmendem Alter der Mutter nimmt auch die Inzidenz zu [2]. Bei der Trisomie 21 treten gehäuft Organfehlbildungen auf. Hierzu zählen in erster Linie Herzfehler, vorwiegend Atriumseptumdefekte (ASD) oder atrioventrikuläre Septumdefekte (AVSD) bei 40–60% der betroffenen. Ebenfalls kommt es gehäuft zur Fallot-Tetralogie. Fallvorstellung

Using vascular closure devices following out-of-hospital cardiac arrest?

Objectives and Background: Despite a generally broad use of vascular closure devices (VCDs), it remains unclear whether they can also be used in victims from out-of-hospital cardiac arrest (OHCA) treated with mild therapeutic hypothermia (MTH). Methods: All victims from OHCA who received immediate coronary angiography after OHCA between January 1st 2008 and December 31st 2013 were included in this study. The operator decided to either use a VCD (Angio-Seal™) or manual compression for femoral artery puncture. The decision to induce MTH was based on the clinical circumstances. Results: 76 patients were included in this study, 46 (60.5%) men and 30 (39.5%) women with a mean age of 64.2 ± 12.8 years. VCDs were used in 26 patients (34.2%), and 48 patients (63.2%) were treated with MTH. While there were significantly more overall vascular complications in the group of patients treated with MTH (12.5% versus 0.0%; p=0.05), vascular complications were similar between patients with VCD or manual compression, regardless of whether or not they were treated with MTH. Conclusion: In our study, the overall rate of vascular complications related to coronary angiography was higher in patients treated with mild therapeutic hypothermia, but was not affected by the application of a vascular closure device. Therefore, our data suggest that the use of VCDs in victims from OHCA might be feasible and safe in patients treated with MTH as well, at least if the decision to use them is individually carefully determined.

Cardiac arrest teams and time of day: effects on surviving in-hospital resuscitation

Objectives Little is known about the factors that influence survival following in-hospital resuscitation, but previous investigations have suggested that in-hospital resuscitations outside of regular working hours are associated with worse survival rates. Material and methods In-hospital cardiac arrest teams at our hospital were instructed to complete a questionnaire following every emergency call between July 2011 and June 2013. Data on all resuscitation attempts were collected and analyzed. Results A total of 65 in-hospital resuscitations were recorded in 42 males (64.6%) and 23 females (35.4%) (mean age 72.0±14.3 years). A total of 54 (83.1%) cardiac arrests were witnessed; seven (10.8%) showed a shockable rhythm at the time of the first ECG. Resuscitation attempts lasted 29.3±41.3 minutes, and 4.1±3.1 mg epinephrine was given. Return of spontaneous circulation could be achieved in 38 patients (58.5%); 29 (44.6%) survived the first day, 23 (35.4%) the seventh day, and 15 patients (23.1%) were discharged alive. Significantly more in-hospital resuscitations were obtained for those performed during non-regular working hours (P<0.001), with higher neuron-specific enolase levels at 72 hours after resuscitation during nonregular working hours (P=0.04). Patients who were discharged alive were significantly younger (P=0.01), presented more often with an initial shockable rhythm (P=0.04), and had a shorter duration of resuscitation (P<0.001) with the need of a lower dose of epinephrine (P<0.001). Discussion Survival rates following in-hospital resuscitation were poor at any time, but appear to depend less on time-dependent effects of the quality of resuscitation and more on time-dependent effects of recognition of cardiac arrests.