Hämodynamisches Monitoring

Hämodynamisches Monitoring ist bei kritisch kranken Patienten essentiell. In der vorliegenden Arbeit wurde ein neues nicht-invasives, ultraschallbasiertes Verfahren (USCOM®, ultrasonic cardiac output monitoring, Fa. UCCOM Ltd., Sydney, Australien) mit den bereits etablierten, auf Thermodilution basierenden Verfahren zur Bestimmung des Herzzeitvolumens, dem Pulmonalarterienkatheter (PAK) und dem PiCCO®-System (pulse induced cardiac output monitoring, Fa. Pulsion, München) verglichen. Insgesamt wurden 50 invasiv-beatmete, katecholaminpflichtige Patienten in die Studie eingeschlossen, wobei 79 Messpaare erhoben wurden im Vergleich zwischen aortalen Untersuchungsgang (USCOM) und PiCCO, sowie 61 Paare zwischen pulmonalarterieller Anlotung und PiCCO. Dabei ergab sich mit einem Korrelationskoeffizient nach Pearson von r=0,69 für den aortalen Vergleich eine gute und für die pulmonalarterielle Untersuchung mit r=0,50 eine mäßige Übereinstimmung. Außerdem wurde der Einfluss des positiven endexspiratorischen Druckes (PEEP) auf das Herzzeitvolumen mit dem USCOM untersucht. Hierbei hat sich gezeigt, dass die Reduktion des PEEP zum Anstieg des Herzzeitvolumens führt. Insgesamt stellt das USCOM-System als nicht-invasives, sehr schnell zu erlernendes Verfahren eine wichtige und interessante Bereicherung für die Intensiv- und Notfallmedizin dar

Pszichoszociális változás és az átalakulás retorikája a tizenkét lépéses mozgalmakban = Psychosocial change and the rhetoric of transformation in Twelve Steps movements

Kutatásunkban felépülő szenvedélybetegek interjúszövegeit vizsgáltuk, komplex tartalomelemző eljárásokkal. Két eltérő felépülési modellt vázoltunk fel: az egyik a domináns kultúrával több izomorfiát mutató Alkoholizmus Ellenes Klubok, a másik pedig a 12-lépéses közösségek alternatív, komplementer jellegű gyakorlata. A 12-lépéses közösségeknél hangsúlyosabb a tanulási folyamat, a személyesen megélt igazság keresése, a kontroll rendszerszintű értelmezése. A markáns dialogikus jelleg és a szelf-reflektivitás arra utal, hogy a tagok az autobiografikus hozzáállás kialakításával, a mentalizációs képesség fejlesztésével segítik a felépülést. Az Alkoholizmus Ellenes Klubok tagjainál gyakoribb a versengés, az „abszolút” típusú kognitív szűrők, az általánosítások, a konverzációs sablonok. Fontosak a kauzális magyarázatok, mint a koherencia megteremtésének legfőbb eszközei, jellemző a spiritualitás konform értelmezése, gyakoribbak a felépülő családjára tett utalások. A felépülés közös tényezői: a sorstársi közösség (közös tapasztalatok, egymás szolgálata); a tág értelemben vett spiritualitás; a törekvés, hogy értelmezzék saját tapasztalataikat, és újrarendezzék saját történeteiket. Újabban a forrás-szűkítések hatására a deficit modellek helyett az erőforrás-alapú felépülési modellek előtérbe kerülnek. Kutatásunk - az egészségtanulás jegyében – előkészítése a generativitás, az intergenerációs transzmisszió megváltoztatása és a poszt-traumás növekedés további kutatási programjainak. | In the current study interviews with recovering addicts were analyzed with complex methods. Two different recovery models were identified: one reflecting the conventions of Anti- Alcoholism Club members, isomorphic with the dominant culture; and the alternative, complementary culture of 12-step fellowships. 12-step communities highlight the learning process during recovery, search for some personal truth, and systemic forms of control. The dialogic nature of the texts, together with self-reflectivity, indicates that members facilitate their recovery by establishing an autobiographic stance and developing mentalization capacity. With AAC members, a competitive approach could be identified. Cognitive filters, generalizations and conventional phrases were characteristic of the texts. Linear causal explanations served as means to establish coherence. Spirituality was understood in a more conservative manner. References to the recovering addict’s family were significantly more frequent. Common factors of recovery: fellows’ community (similar experiences, serving one another); spirituality (in any sense); striving for making meaning of own experiences, and restructure personal stories accordingly. Recently, strength-based recovery models as cost-effective therapeutic solutions have been emphasized. Our research may serve as a basis for further studies in health learning concerning generativity, changing intergenerational transmission models and post-traumatic growth

Cardiac Output Measurements in Septic Patients: Comparing the Accuracy of USCOM to PiCCO

USCOM is an ultrasound-based method which has been accepted for noninvasive hemodynamic monitoring in various clinical conditions (USCOM, Ultrasonic cardiac output monitoring). The present study aimed at comparing the accuracy of the USCOM device with that of the thermodilution technique in patients with septicemia. We conducted a prospective observational study in a medical but noncardiological ICU of a university hospital. Septic adult patients (median age 55 years, median SAPS-II-Score 43 points) on mechanical ventilation and catecholamine support were monitored with USCOM and PiCCO (n = 70). Seventy paired left-sided CO measurements (transaortic access = COUS-A) were obtained. The mean COUS-A were 6.55 l/min (±2.19) versus COPiCCO 6.5 l/min (±2.18). The correlation coefficient was r = 0.89. Comparison by Bland-Altman analysis revealed a bias of −0.36 l/min (±0.99 l/min) leading to a mean percentage error of 29%. USCOM is a feasible and rapid method to evaluate CO in septic patients. USCOM does reliably represent CO values as compared to the reference technique based on thermodilution (PiCCO). It seems to be appropriate in situations where CO measurements are most pertinent to patient management

No Differences in Renal Function between Balanced 6% Hydroxyethyl Starch (130/0.4) and 5% Albumin for Volume Replacement Therapy in Patients Undergoing Cystectomy: a Randomized Controlled Trial

BACKGROUND The use of artificial colloids has declined in critical care, whereas they are still used in perioperative medicine. Little is known about the nephrotoxic potential in noncritically ill patients during routine surgery. The objective of this trial was to evaluate the influences of albumin 5% and balanced hydroxyethyl starch 6% (130/0.4) on renal function and kidney injury. METHODS One hundred urologic patients undergoing elective cystectomy were randomly assigned for this prospective, single-blinded, controlled study with two parallel groups to receive either albumin 5% or balanced hydroxyethyl starch 6% (130/0.4) as the only perioperative colloid. The primary endpoint was the ratio of serum cystatin C between the last visit at day 90 and the first preoperative visit. Secondary endpoints were estimated glomerular filtration rate and serum neutrophil gelatinase-associated lipocalin until the third postoperative day and risk, injury, failure, loss, and end-stage renal disease criteria at postoperative days 3 and 90. RESULTS The median cystatin C ratio was 1.11 (interquartile range, 1.01 to 1.23) in the albumin and 1.08 (interquartile range, 1.00 to 1.20) in the hydroxyethyl starch group (median difference = 0.03; 95% CI, -0.09 to 0.08; P = 0.165). Also, there were no significant differences concerning serum cystatin C concentrations; estimated glomerular filtration rate; risk, injury, failure, loss, and end-stage renal disease criteria; and neutrophil gelatinase-associated lipocalin. Infusion requirements, transfusion rates, and perioperative hemodynamics were similar in both groups. CONCLUSIONS With respect to renal function and kidney injury, this study indicates that albumin 5% and balanced hydroxyethyl starch 6% have comparable safety profiles in noncritically ill patients undergoing major surgery

Gender-Specific Differences in Low-Dose Haloperidol Response for Prevention of Postoperative Nausea and Vomiting: A Register-Based Cohort Study

Postoperative nausea and vomiting (PONV) is one of the most common and distressing complications after general anesthesia and surgery, with young non-smoking females receiving postoperative opioids being high-risk patients. This register-based study aims to evaluate the effect of low-dose haloperidol (0.5 mg intravenously) directly after induction of general anesthesia to reduce the incidence of PONV in the postoperative anesthesiological care unit (PACU).Multivariable regression models were used to investigate the association between low-dose haloperidol and the occurrence of PONV using a patient registry containing 2,617 surgical procedures carried out at an university hospital.Haloperidol 0.5 mg is associated with a reduced risk of PONV in the total collective (adjusted odds ratio = 0.75, 95% confidence interval: [0.56, 0.99], p = 0.05). The results indicate that there is a reduced risk in male patients (adjusted odds ratio = 0.45, 95% confidence interval: [0.28, 0.73], p = 0.001) if a dose of 0.5 mg haloperidol was administered while there seems to be no effect in females (adjusted odds ratio = 1.02, 95% confidence interval: [0.71, 1.46], p = 0.93). Currently known risk factors for PONV such as female gender, duration of anesthesia and the use of opioids were confirmed in our analysis.This study suggests that low-dose haloperidol has an antiemetic effect in male patients but has no effect in female patients. A confirmation of the gender-specific effects we have observed in this register-based cohort study might have major implications on clinical daily routine

Changes of hemodynamic and cerebral oxygenation after exercise in normobaric and hypobaric hypoxia: associations with acute mountain sickness

Objective: Normobaric (NH) and hypobaric hypoxia (HH) are associated with acute mountain sickness (AMS) and cognitive dysfunction. Only few variables, like heart-rate-variability, are correlated with AMS. However, prediction of AMS remains difficult. We therefore designed an expedition-study with healthy volunteers in NH/HH to investigate additional non-invasive hemodynamic variables associated with AMS.Methods: Eleven healthy subjects were examined in NH (FiO(2) 13.1%;equivalent of 3.883m a.s.l;duration 4h) and HH (3.883ma.s.l.;duration 24h) before and after an exercise of 120min. Changes in parameters of electrical cardiometry (cardiac index (CI), left-ventricular ejection time (LVET), stroke volume (SV), index of contractility (ICON)), near-infrared spectroscopy (cerebral oxygenation, rScO(2)), Lake-Louise-Score (LLS) and cognitive function tests were assessed. One-Way-ANOVA, Wilcoxon matched-pairs test, Spearman's-correlation-analysis and Student's t-test were performed.Results: HH increased heart rate (HR), mean arterial pressure (MAP) and CI and decreased LVET, SV and ICON, whereas NH increased HR and decreased LVET. In both NH and HH cerebral oxygenation decreased and LLS increased significantly. After 24h in HH, 6 of 11 subjects (54.6%) developed AMS. LLS remained increased until 24h in HH, whereas cognitive function remained unaltered. In HH, HR and LLS were inversely correlated (r=-0.692;p<0.05). More importantly, the rScO2-decrease after exercise in NH significantly correlated with LLS after 24h in HH (r=-0.971;p<0.01) and rScO2 correlated significantly with HR (r=0.802;p<0.01), CI (r=0.682;p<0.05) and SV (r=0.709;p<0.05) after exercise in HH.Conclusion: sBoth acute NH and HH altered hemodynamic and cerebral oxygenation and induced AMS. Subjects, who adapted their CI had higher rScO2 and lower LLS. Furthermore, rScO2 after exercise under normobaric conditions was associated with AMS at high altitudes

Mast cell activation disease: a concise practical guide for diagnostic workup and therapeutic options

Mast cell activation disease comprises disorders characterized by accumulation of genetically altered mast cells and/or abnormal release of these cells' mediators, affecting functions in potentially every organ system, often without causing abnormalities in routine laboratory or radiologic testing. In most cases of mast cell activation disease, diagnosis is possible by relatively non-invasive investigation. Effective therapy often consists simply of antihistamines and mast cell membrane-stabilising compounds supplemented with medications targeted at specific symptoms and complications. Mast cell activation disease is now appreciated to likely be considerably prevalent and thus should be considered routinely in the differential diagnosis of patients with chronic multisystem polymorbidity or patients in whom a definitively diagnosed major illness does not well account for the entirety of the patient's presentation