[Show abstract][Hide abstract] ABSTRACT: In patients awaiting lung transplantation (LTX), adequate gas exchange may not be sufficiently achieved by mechanical ventilation alone if acute respiratory decompensation arises. We report on 20 patients with life-threatening hypercapnia who received extracorporeal CO2-removal (ECCO2-R) by means of the interventional lung assist (ILA®, Novalung, Germany) as bridge to LTX. The most common underlying diagnoses were bronchiolitis obliterans syndrome, cystic fibrosis, and idiopathic pulmonary fibrosis, respectively. The type of ILA was pumpless arterio-venous or pump-driven veno-venous (ILA activve®, Novalung, Germany) in 10 patients each. ILA bridging was initiated in 15 invasively ventilated and 5 non-invasively ventilated patients, of whom 1 had to be intubated prior to LTX. Hypercapnia and acidosis were effectively corrected in all patients within the first 12 hours of ILA therapy: PaCO2 declined from 109 (70-146) to 57 (45-64) mmHg, P < 0.0001; pH increased from 7.20 (7.06-7.28) to 7.39 (7.35-7.49), P < 0.0001. Four patients were switched to extracorporeal membrane oxygenation due to progressive hypoxia or circulatory failure. Nineteen patients (95%) were successfully transplanted. Hospital and 1-year survival was 75 and 72%, respectively. Bridging to LTX with ECCO2-R delivered by arterio-venous pumpless or veno-venous pump-driven ILA is feasible and associated with high transplantation and survival rates.This article is protected by copyright. All rights reserved.
Transplant International 11/2014; · 3.16 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Veno-venous extracorporeal membrane oxygenation (vv-ECMO) is pivotal in the treatment of patients suffering from acute respiratory distress syndrome (ARDS). Comparative data with different oxygenator models have not yet been reported. The aim of this retrospective investigation was therefore to assess whether different oxygenator types might influence changing frequency, infection incidence, and mortality in patients on vv-ECMO.
The International journal of artificial organs 10/2014; · 1.45 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Prognostic factors and outcomes of cancer patients with acute organ failure receiving chemotherapy (CT) in the intensive care unit (ICU) are still incompletely described. We therefore retrospectively studied all patients who received CT in any ICU of our institution between October 2006 and November 2013. Fifty-six patients with hematologic (n = 49; 87.5 %) or solid (n = 7; 12.5 %) malignancies, of which 20 (36 %) were diagnosed in the ICU, were analyzed [m/f ratio, 33:23; median age, 47 years (IQR 32 to 62); Charlson Comorbidity Index (CCI), 3 (2 to 5); Simplified Acute Physiology Score II (SAPS II), 50 (39 to 61)]. The main reasons for admission were acute respiratory failure, acute kidney failure, and septic shock. Mechanical ventilation and vasopressors were employed in 34 patients (61 %) respectively, hemofiltration in 22 (39 %), and extracorporeal life support in 7 (13 %). Twenty-seven patients (48 %) received their first CT in the ICU. Intention of therapy was cure in 46 patients (82 %). Tumor lysis syndrome (TLS) developed in 20 patients (36 %). ICU and hospital survival was 75 and 59 %. Hospital survivors were significantly younger; had lower CCI, SAPS II, and TLS risk scores; presented less often with septic shock; were less likely to develop TLS; and received vasopressors, hemofiltration, and thrombocyte transfusions in lower proportions. After discharge, 88 % continued CT and 69 % of 1-year survivors were in complete remission. Probability of 1- and 2-year survival was 41 and 38 %, respectively. Conclusively, administration of CT in selected ICU cancer patients was feasible and associated with considerable long-term survival as well as long-term disease-free survival.
Annals of Hematology 07/2014; · 2.40 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: ILA Activve is a new minimally invasive device for extracorporeal CO2-removal (ECCO2-R) using a miniaturized pump, a special gas exchange membrane and a double lumen cannula. We retrospectively analyzed our experiences in twelve patients with hypercapnic respiratory failure undergoing ECCO2-R.Indication for ECCO2-R was hypercapnia due to terminal lung failure during bridging to lung transplantation, pneumonia, and COPD or asthma, respectively. The median duration of ECCO2-R was 8 days (range 2-30). Seven patients were successfully weaned, five died. Patients with primarily hypoxic lung failure were significantly longer ventilated prior to ECCO2-R and had a higher mortality rate. Complications were a retroperitoneal hematoma after cannulation in one patient and repeated system changes due to clotting in two patients. We observed effective CO2 removal in all patients with significant reduction of ventilation pressures and minute volumes at median blood flow rates of 1.2 - 1.4 L/min.The iLA Activve system using venous double lumen cannulas proved to be an effective method for extracorporeal CO2 removal. Invasiveness of ventilation could be reduced. Additional severe impairment of oxygenation or prolonged mechanical ventilation prior to ECCO2-R are factors of adverse prognosis. Use of ECCO2-R should be thoroughly reconsidered in these cases.
ASAIO journal (American Society for Artificial Internal Organs: 1992) 04/2014; · 1.39 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: A patient suffering from severe cutaneous graft versus host disease (GvHD) developed generalized epidermolysis and refractory hypothermia. Due to the insufficient effect of traditional rewarming methods, an endovascular temperature catheter was placed via the femoral vein to achieve and maintain normothermia over a period of 31 days. This case shows that an endovascular temperature modulation device primarily made for short-term use may be safe and effective even over weeks and may offer an alternative to other rewarming methods in patients with severe epidermolysis and burns.
Medizinische Klinik, Intensivmedizin und Notfallmedizin. 03/2014;
[Show abstract][Hide abstract] ABSTRACT: Background Increased elevation of the head of the bed is linked to a higher risk for sacral pressure ulcers. A semirecumbent position of at least 30° is recommended for the prevention of ventilator-associated pneumonia in patients treated with mechanical ventilation. Therefore, prevention of pressure ulcers and prevention of pneumonia seem to demand contradictory, possibly incompatible, positioning. Objectives To measure pressure at the interface between sacral skin and the supporting surface in healthy volunteers at different degrees of upright position with different types of mattresses. Methods An open, prospective, randomized crossover trial was conducted with 20 healthy volunteers. Interface pressure was measured by using a pressure mapping device with the participant in a supine position at 0, 10°, 30°, and 45° elevation and in the reverse Trendelenburg position at 10° and 30°. Four types of mattresses were examined: 2 different foam mattresses and 2 air suspension beds, 1 of the latter with low-air-loss technology. Results Peak sacral interface pressures increased significantly only at 45° of backrest elevation (P < .001). A mattress system with low-air-loss technology significantly reduced peak interface pressures at all angles (P < .001). The reverse Trendelenburg position led to lower peak pressures for all positions (P = .01). Conclusions Backrest elevation up to 30° might be a compromise between the seemingly incompatible demands of skin integrity and the prevention of ventilator-associated pneumonia. The reverse Trendelenburg position and a mattress system with low-air-loss technology could be additional useful tools to help prevent skin breakdown at the sacrum.
American Journal of Critical Care 03/2014; 23(2):119-26. · 1.41 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background
Infections are a leading cause of death in patients with advanced cirrhosis, but there are relatively few data on the epidemiology of infection in intensive care unit (ICU) patients with cirrhosis. AimsWe used data from the Extended Prevalence of Infection in Intensive Care (EPIC) II one-day point-prevalence study to better define the characteristics of infection in these patients. Methods
We compared characteristics, including occurrence and types of infections in non-cirrhotic and cirrhotic patients who had not undergone liver transplantation. ResultsThe EPIC II database includes 13,796 adult patients from 1,265 ICUs: 410 of the patients had cirrhosis. The prevalence of infection was higher in cirrhotic than in non-cirrhotic patients (59 vs. 51%, p<0.01). The lungs were the most common site of infection in all patients, but abdominal infections were more common in cirrhotic than in non-cirrhotic patients (30 vs. 19%, p<0.01). Infected cirrhotic patients more often had Gram-positive (56 vs. 47%, p<0.05) isolates than did infected non-cirrhotic patients. Methicillin-resistant Staphylococcus aureus (MRSA) was more frequent in cirrhotic patients. The hospital mortality rate of cirrhotic patients was 42%, compared to 24% in the non-cirrhotic population (p<0.001). Severe sepsis and septic shock were associated with higher in-hospital mortality rates in cirrhotic than in non-cirrhotic patients (41% and 71% vs. 30% and 49%, respectively, p<0.05). Conclusions
Infection is more common in cirrhotic than in non-cirrhotic ICU patients and more commonly due to Gram-positive organisms, including MRSA. Infection in patients with cirrhosis was associated with higher mortality rates than in non-cirrhotic patients.This article is protected by copyright. All rights reserved.
Liver international: official journal of the International Association for the Study of the Liver 03/2014; · 4.41 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Acute respiratory failure (ARF) is the main reason for intensive care unit (ICU) admissions in patients with hematologic malignancies (HM). We report the first series of adult patients with ARF and HM treated with extracorporeal membrane oxygenation (ECMO).
This is a retrospective cohort study on 14 patients with HM (aggressive non-Hodgkin lymphoma (NHL) n = 5; highly aggressive NHL, that is acute lymphoblastic leukemia or Burkitt's lymphoma, n = 5; Hodgkin's lymphoma, n = 2; acute myeloid leukemia, n = 1; multiple myeloma, n = 1) receiving ECMO support due to ARF (all data as medians and interquartile ranges; age: 32 years (22 to 51); simplified acute physiology score II (SAPS II): 51 (42 to 65)). Etiology of ARF was pneumonia (n = 10), thoracic manifestation of NHL (n = 2), sepsis of non-pulmonary origin (n = 1), and transfusion related acute lung injury (n = 1). Diagnosis of HM was established during ECMO in four patients, and five firstly received (immuno-) chemotherapy on ECMO.
Prior to ECMO, the PaO2/FiO2-ratio was 60 (53 to 65) and the lung injury score 3.3 (3.3 to 3.7). Three patients received veno-arterial ECMO due acute circulatory failure in addition to ARF, all other patients received veno-venous ECMO. All patients needed vasopressors and five needed hemofiltration. Thrombocytopenia occurred in all patients (lowest platelet count was 20 (11 to 21) G/L). Five major bleeding events were noted. ECMO duration was 8.5 (4 to 16) days. ICU and hospital survival was 50%. All survivors were alive at follow-up (36 (10 to 58) months), five patients were in complete remission, one in partial remission, and one had relapsed.
ECMO therapy is feasible in selected patients with HM and ARF and can be associated with long-term disease-free survival.
Critical care (London, England) 01/2014; 18(1):R20. · 5.04 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The occurrence of hyperleukocytosis (leukocytes > 100.000/μl) is associated with complications such as leukostasis, tumor lysis and consumption coagulopathy in patients with acute leukemia much more often than in patients with chronic malignant hematological diseases. To manage these situations may be complex as organ failure is often imminent or manifest, infectious complications arise and indications for induction chemotherapy are usually urgent. Prophylaxis and therapy of the tumor lysis syndrome consists of hydration, lowering of uric acid and the management of electrolyte disturbances. Leukostasis requires immediate reduction of the leukocyte count by leukapheresis, administration of hydroxycarbamide and, ultimately, by causative and specific treatment of the underlying disease itself. In patients with curable diseases or favorable long-term prognosis, transfer to the intensive care unit must be evaluated early in the course of impending organ dysfunction, especially in cases of acute respiratory failure.
[Show abstract][Hide abstract] ABSTRACT: Background
Patients with follicular lymphoma ineligible for standard treatment with the anti-CD20 antibody rituximab represent a considerable challenge as they require alternative therapeutic approaches.
Patient and methods
We describe a patient who experienced a severe episode of serum sickness. Antichimeric antibodies against rituximab were verified in an early stage of disease, rendering further use of the drug impossible. After five treatment lines he developed progressive follicular lymphoma with skin involvement, which was treated with lenalidomide monotherapy.
Six cycles of lenalidomide monotherapy (25 mg orally for 21 days, 1 week off) led to a very good partial response rendering the patient eligible for autologous stem cell transplantation. Data on efficacy of lenalidomide in follicular lymphoma are reviewed.
As shown here, single-agent lenalidomide represent a therapeutic option for pretreated patients with follicular lymphoma ineligible for rituximab.
memo - Magazine of European Medical Oncology 06/2013; 6(2).
[Show abstract][Hide abstract] ABSTRACT: Sepsis is one of the leading causes of death in intensive care units (ICUs) and has enormous relevance in health economics. There is growing evidence, however, that a significant percentage of patients with sepsis are not treated in an ICU. The aim of this study was to describe the epidemiology and short- and long-term mortality of sepsis according to patients' location on general wards or in an ICU over a period of a year. We retrospectively collected data on patients with sepsis admitted to the General Hospital of Vienna during a 12-month period. We used world health organization (WHO) ICD-10 classification as the selection criterion and analyzed demographic data, length of stay, and 28-day, hospital, and 3-year mortality on general wards and in the ICU. A total of 68,305 inpatient admission episodes between January 1 and December 31, 2007 were screened for sepsis. Using ICD-10 codes we identified 139 patients with sepsis, giving a cumulative hospital incidence of 2 cases/1,000 admissions; 32 % of these patients needed ICU treatment. The overall 28-day mortality rate was 29.5 %, increasing to 55.4 % 3 years after hospital discharge. On general wards the 28-day mortality rate was 12.6 %, increasing to 42.1 % 3 years after discharge; the respective rates for the ICU were 65.9 and 84.1 %. Sepsis is a disease of predominantly elderly patients. The majority of sepsis occurred on general wards and about 30 % in the ICU. Considerable number of patients with sepsis on general wards died after hospital discharge, thus the often used 28-day in-hospital mortality rate may fail to capture the true impact of sepsis on subsequent outcome.
Wiener klinische Wochenschrift 05/2013; 125(11-12). · 0.79 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background
Acute respiratory distress syndrome is characterized by damage to the lung caused by various insults, including ventilation itself, and tidal hyperinflation can lead to ventilator induced lung injury (VILI). We investigated the effects of a low tidal volume (V
T) strategy (V
T ≈ 3 ml/kg/predicted body weight [PBW]) using pumpless extracorporeal lung assist in established ARDS.
Seventy-nine patients were enrolled after a ‘stabilization period’ (24 h with optimized therapy and high PEEP). They were randomly assigned to receive a low V
T ventilation (≈3 ml/kg) combined with extracorporeal CO2 elimination, or to a ARDSNet strategy (≈6 ml/kg) without the extracorporeal device. The primary outcome was the 28-days and 60-days ventilator-free days (VFD). Secondary outcome parameters were respiratory mechanics, gas exchange, analgesic/sedation use, complications and hospital mortality.
Ventilation with very low V
T’s was easy to implement with extracorporeal CO2-removal. VFD’s within 60 days were not different between the study group (33.2 ± 20) and the control group (29.2 ± 21, p = 0.469), but in more hypoxemic patients (PaO2/FIO2 ≤150) a post hoc analysis demonstrated significant improved VFD-60 in study patients (40.9 ± 12.8) compared to control (28.2 ± 16.4, p = 0.033). The mortality rate was low (16.5 %) and did not differ between groups.
The use of very low V
T combined with extracorporeal CO2 removal has the potential to further reduce VILI compared with a ‘normal’ lung protective management. Whether this strategy will improve survival in ARDS patients remains to be determined (Clinical trials NCT 00538928).
Intensive Care Medicine 05/2013; 39(5). · 5.54 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: Estimating attributable mortality of ventilator-associated pneumonia has been hampered by confounding factors, small sample sizes, and the difficulty of doing relevant subgroup analyses. We estimated the attributable mortality using the individual original patient data of published randomised trials of ventilator-associated pneumonia prevention. METHODS: We identified relevant studies through systematic review. We analysed individual patient data in a one-stage meta-analytical approach (in which we defined attributable mortality as the ratio between the relative risk reductions [RRR] of mortality and ventilator-associated pneumonia) and in competing risk analyses. Predefined subgroups included surgical, trauma, and medical patients, and patients with different categories of severity of illness scores. FINDINGS: Individual patient data were available for 6284 patients from 24 trials. The overall attributable mortality was 13%, with higher mortality rates in surgical patients and patients with mid-range severity scores at admission (ie, acute physiology and chronic health evaluation score [APACHE] 20-29 and simplified acute physiology score [SAPS 2] 35-58). Attributable mortality was close to zero in trauma, medical patients, and patients with low or high severity of illness scores. Competing risk analyses could be done for 5162 patients from 19 studies, and the overall daily hazard for intensive care unit (ICU) mortality after ventilator-associated pneumonia was 1·13 (95% CI 0·98-1·31). The overall daily risk of discharge after ventilator-associated pneumonia was 0·74 (0·68-0·80), leading to an overall cumulative risk for dying in the ICU of 2·20 (1·91-2·54). Highest cumulative risks for dying from ventilator-associated pneumonia were noted for surgical patients (2·97, 95% CI 2·24-3·94) and patients with mid-range severity scores at admission (ie, cumulative risks of 2·49 [1·81-3·44] for patients with APACHE scores of 20-29 and 2·72 [1·95-3·78] for those with SAPS 2 scores of 35-58). INTERPRETATION: The overall attributable mortality of ventilator-associated pneumonia is 13%, with higher rates for surgical patients and patients with a mid-range severity score at admission. Attributable mortality is mainly caused by prolonged exposure to the risk of dying due to increased length of ICU stay. FUNDING: None.
The Lancet Infectious Diseases 04/2013; · 19.45 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Critically ill cancer patients on intensive units with hematological or oncological underlying diseases are a special situation: the underlying disease may be incurable, acute problems are often therapy associated and immunosuppression is regularly present. Due to evolving knowledge about special aspects of these patients and optimized supportive therapy, the prognosis has substantially improved during the last decades. General reluctance to admit cancer patients to an intensive care unit is therefore no longer justified. Reasons for admission are often infections and/or respiratory failure. Extensive diagnostic measures, causal and supportive therapy of sepsis according to current guidelines has led to improved outcome even in cancer patients. In respiratory failure, non-invasive ventilation is the key to improved prognosis if used early enough and indications, contraindications and break-off criteria are strictly followed. The prognosis of critically ill cancer patients is determined by the severity of the acute problem and not by the underlying disease.
Medizinische Klinik, Intensivmedizin und Notfallmedizin. 03/2013;
[Show abstract][Hide abstract] ABSTRACT: Many factors contribute to making critically ill patients with underlying hematological or oncological diseases into a special collective on intensive care units, such as an often incurable or at least doubtfully curable underlying disease, therapy associated complications and a commonly present immunosuppression. The prognosis of these patients has clearly improved in recent years so that a general reluctance in deciding to treat these patients in intensive care units can no longer be justified. Comprehensive infection diagnostics and a guideline oriented causal and supportive treatment can improve the prognosis of sepsis even in hematology/oncology patients. In the therapy of respiratory failure non-invasive ventilation is of great importance for a reduction in mortality if used early and contraindications, such as termination criteria are considered. Considerations on long-term prognosis, quality of life and palliative care are increasingly becoming topics in intensive care medicine.
Medizinische Klinik, Intensivmedizin und Notfallmedizin. 02/2013;
[Show abstract][Hide abstract] ABSTRACT: Das Auftreten einer Hyperleukozytose mit peripherer Leukozytenzahl > 100.000/μl ist bei akuten Leukämien wesentlich häufiger als bei chronisch verlaufenden malignen hämatologischen Systemerkrankungen mit dem Auftreten bedrohlicher Komplikationen wie Leukostase, Tumorlyse und Verbrauchskoagulopathie vergesellschaftet. Klinisch handelt es sich in der Regel um komplexe Situationen mit drohendem oder manifestem Organversagen, Infektionskomplikationen sowie einer Indikation für den kurzfristigen Beginn oder die Fortführung einer Induktionschemotherapie. Während die Prophylaxe bzw. Therapie des Tumorlysesyndroms in Hydrierung, Harnsäuresenkung und Ausgleich des Elektrolythaushalts besteht, erfordert eine klinisch manifeste Leukostase die rasche Reduktion der Zellzahl durch Leukapherese, Hydroxycarbamid und schließlich eine kausale und spezifische Therapie der Grunderkrankung. Treten bei Patienten mit kurativen Therapieansätzen oder guter Langzeitprognose Organdysfunktionen auf, muss insbesondere bei respiratorischem Versagen frühzeitig eine Evaluation der intensivmedizinischen Therapieoptionen erfolgen.
Der Internist 01/2013; 54(9). · 0.27 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: In recent years the range of products for extracorporeal lung support has substantially expanded. In principle systems generating high blood flow and thus enabling oxygenation and decarboxylation, corresponding to classical extracorporeal membrane oxygenation (ECMO), can be distinguished from low-flow systems, enabling decarboxylation only. Technical progress and new data have led to a novel insight into the role of ECMO as an invasive, ultimate therapy in refractory life-threatening lung failure towards a broader range of applications even in spontaneously breathing and awake patients. Indications for extracorporeal decarboxylation, initially thought to enable most protective ventilator settings, have been extended to forms of hypercapnic lung failure and towards avoidance of intubation and mechanical ventilation itself in patients with isolated hypercapnia and failure of non-invasive ventilation. It has to be emphasized however, that due to a still sparse amount of literature and potentially deleterious complications associated with extracorporeal lung support, these kinds of therapies should be reserved for specialized and experienced centers.
Medizinische Klinik, Intensivmedizin und Notfallmedizin. 10/2012;