[Show abstract][Hide abstract] ABSTRACT: Deficiency in the serine protease inhibitor, alpha-1 antitrypsin (AAT), is known to cause emphysema and liver disease. Other manifestations, including airway disease or skin disorders, have also been described. A 44-year-old woman presented to our emergency department with dyspnea and respiratory insufficiency. She had never smoked, and had been diagnosed with COPD 9 years earlier. Three months previously, she had suffered a pulmonary embolism. Chest computed tomography scan revealed severe cystic bronchiectasis with destruction of the lung parenchyma. The sweat test was normal and there was no evidence of the cystic fibrosis transmembrane conductance regulator (CFTR) mutation. Capillary zone electrophoresis showed a decrease of alpha-1 globin band and AAT levels were below the quantification limit (<25 mg/dL). No S or Z mutation was identified, but sequencing analysis found a homozygous cytosine and adenine (CA) insertion in exon 2 of the SERPINA-1 gene, probably leading to a dysfunctional protein (PI Null/Null). This mutation has not been previously identified. The atypical presentation of the patient, with severe cystic bronchiectasis, highlights AAT deficiency as a differential diagnosis in bronchiectasis. Further, awareness should be raised regarding a possible increased risk of thromboembolism associated with AAT deficiency.
International Journal of COPD 05/2015; 10:891. DOI:10.2147/COPD.S80173
[Show abstract][Hide abstract] ABSTRACT: We report the case of a young female lung transplant recipient with difficult-to-treat cytomegalovirus (CMV) disease. While treatment with intravenous (IV) ganciclovir failed due to antiviral drug resistance, a trial with foscarnet resulted in severe side effects. In addition, the patient received IV CMV-specific immune globulins as adjunctive therapy and leflunomide as experimental therapy. In this context, CMV-specific immune monitoring was performed and was successfully implemented in management decisions. The patient was screened for acquisition of an adaptive immune response, and antiviral prophylaxis and therapy was tailored according to results. This report highlights the impact of CMV-specific immune monitoring on individualized therapy for appropriate prophylaxis and management of CMV infection and diseases.
[Show abstract][Hide abstract] ABSTRACT: Background In December 2011, the Eurotransplant Foundation (Leiden, The Netherlands) changed the allocation system for donor lungs from a model based on urgency and waiting time to the lung allocation score (LAS). Objective The aim of the study was to investigate the effects of the LAS implementation on the early outcome after lung transplantation in Germany. Methods We therefore retrospectively studied the outcome of the last 50 patients transplanted before and the first 50 patients transplanted after LAS implementation. Results Both patient groups were comparable in baseline characteristics at the time of transplantation. Postoperative hospital stays were comparable between the groups, that is, 40.3 ± 26.8 and 40.3 ± 31.3 days (p = 0.992). Also, survival rates on intensive care, during entire hospital stay, at 90 days, 6 month, and 1 year after transplant were comparable between the groups. The retrospectively calculated LASs of the patients transplanted under the old allocation system were not statistically significantly different from those after LAS implementation, that is, 46.5 ± 14.2 and 51.2 ± 17.4 (p = 0.139). Conclusion We demonstrate, for the first time, that implementation of the LAS in Germany had no negative effect on the early outcome after lung transplantation. Our data indicate that patients transplanted before implementation of the LAS had a similar prospective transplant benefit.
The Thoracic and Cardiovascular Surgeon 09/2014; DOI:10.1055/s-0034-1387821 · 1.08 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Obesity is a worldwide pandemic, and obese patients face an increased risk of developing acute respiratory distress syndrome (ARDS). Prone positioning (PP) is a frequently used intervention in the treatment of ARDS. There are no data describing the impact of PP on morbidity and mortality in abdominally obese patients. We report our observations in abdominally obese ARDS patients treated with PP.
Patients with ARDS (n = 82) were retrospectively divided into 2 groups characterized by presence (n = 41) or absence (n = 41) of abdominal obesity as defined by a sagittal abdominal diameter of 26 cm or more.
There was no difference in cumulative time abdominally obese patients were placed in prone position from admission to day 7 (41.0 hours [interquartile range, 50.5 hours] vs 39.5 hours [interquartile range, 61.5 hours]; P = .65) or in overall intensive care unit mortality (34% vs 34%; P = 1). However, abdominally obese patients developed renal failure (83% vs 35%; P < .001) and hypoxic hepatitis (22% vs 2%; P = .015) more frequently. A significant interaction effect between abdominal obesity and prone position with respect to mortality risk (likelihood ratio, P = .0004) was seen if abdominally obese patients were treated with prolonged cumulative PP.
A cautious approach to PP should be considered in abdominally obese patients.
Journal of critical care 02/2014; 29(4). DOI:10.1016/j.jcrc.2014.02.010 · 2.19 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Purpose
Obesity is a worlwide pandemic and obese patients face an increased risk of developing acute respiratory distress syndrome (ARDS). Prone positioning, a frequently used intervention in the treatment of ARDS. There are no data describing the impact of prone positioning on morbidity and mortality in abdominally obese patients. We report our observations in abdominally obese ARDS patients treated with prone positioning.
Material and methods
Patients with ARDS (n = 82) were retrospectively divided into two groups characterised by presence (n = 41) or absence (n = 41) of abdominal obesity as defined by a sagittal abdominal diameter of ≥ 26 cm.
There was no difference in cumulative time abdominally obese patients were placed in prone position from admission to day 7 [41.0 h (IQR 50.5 h) vs. 39.5 h (IQR 61.5 h); p = .65)] or in overall ICU mortality (34% vs. 34%; p = 1). However, abdominally obese patients developed renal failure (83% vs. 35%; p < .001) and hypoxic hepatitis (22% vs. 2%; p = .015) more frequently. A significant interaction effect between abdominal obesity and prone position with respect to mortality risk (likelihood ratio p = .0004) was seen if abdominally obese patients were treated with prolonged cumulative prone positioning.
A cautious approach to prone positioning should be considered in abdominally obese patients.
[Show abstract][Hide abstract] ABSTRACT: Objective and Methods The Eurotransplant Foundation introduced the lung allocation score (LAS) in Germany on December 10, 2011. We analyzed characteristics of the Munich Lung Transplant Group (MLTG) waiting list during the first 9 months after the introduction of the LAS. Results A mean number of 39 ± 1 patients were constantly listed for lung transplantation and 60 transplants were performed by the MLTG during the observation period. While the majority (42 ± 0%) of patients waiting for transplant comprised chronic obstructive pulmonary disease (COPD)/emphysema patients, only 26% of transplanted patients suffered from COPD/emphysema. Instead, the majority (42%) of transplanted patients suffered from interstitial lung disease. Waiting times did not markedly change in the LAS era. Notably, patients with interstitial lung disease had shorter waiting times when compared with patients suffering from COPD/emphysema and cystic fibrosis, both on the waiting list and at the time of transplant. Conclusion The MLTG lung transplant waiting list has not markedly changed during the first 9 months after the introduction of the LAS. Our data indicate that the LAS accommodates disease-specific patient statuses well. Although patients with interstitial lung disease are preferably transplanted, the LAS system provides a very reasonable basis to also list and transplant COPD/emphysema patients.
The Thoracic and Cardiovascular Surgeon 12/2013; 62(5). DOI:10.1055/s-0033-1345021 · 1.08 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Hypoxic hepatitis is a common cause of hepatic impairment in critically ill patients and is an independent risk factor for mortality. An elevated level of unmeasured anions is another unfavourable prognostic marker in many disease entities. While the biochemical nature of unmeasured anions is unknown, data suggest that they may be released from the liver. Therefore, the purpose of this study was to determine whether the strong ion gap-the gold standard for estimation of unmeasured anions-is elevated and associated with outcome in patients with hypoxic hepatitis.
One hundred and five consecutive patients with hypoxic hepatitis admitted to the (intensive care unit) ICU of a university hospital were prospectively included in the study and compared with 15 healthy controls.
Compared with the controls, patients with hypoxic hepatitis had an elevated strong ion gap (4.0 ± 2.6 vs. 7.8 ± 4.0 mmol/L; p = 0.0002) that contributed to metabolic acidosis. Patients dying within 5 days had a larger strong ion gap upon admission than did patients surviving beyond 5 days. The mean strong ion gap (SIG) over the course of the first 5 days after admission to the ICU was 1.3 mmol/L (0.3-2.3 mmol/L) larger in patients who died compared with patients who survived, p = 0.008. In multivariate Cox-regression, larger strong ion gaps were associated with shorter survival time. The SIG correlated positively with both AST and ALT.
Unmeasured anions are elevated in patients with hypoxic hepatitis, contribute to metabolic acidosis and are associated with mortality. The liver is a possible source of the unmeasured anions, which may represent markers of tissue damage in hypoxic hepatitis.
Wiener klinische Wochenschrift 07/2013; 125(15-16). DOI:10.1007/s00508-013-0400-9 · 0.79 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Early initiation of appropriate antimicrobial treatment is a cornerstone in managing pneumonia. Since microbiological processing may not be available around the clock, optimal storage of specimens is essential for accurate microbiological identification of pathogenetic bacteria. The aim of our study was to determine the accuracy of two commonly used storage approaches for delayed processing of bronchoalveolar lavage in critically ill patients with suspected pneumonia.
This study included 132 patients with clinically suspected pneumonia at two medical intensive care units of a tertiary care hospital. Bronchoalveolar lavage samples were obtained and divided into three aliquots: one was used for immediate culture and two for delayed culture (DC) after storage for 24 hours at 4 degrees C (DC4) and -80 degrees C (DC-80), respectively.
Of 259 bronchoalveolar lavage samples, 84 (32.4%) were positive after immediate culture with 115 relevant culture counts ([greater than or equal to] 104 colony forming units/ml). Reduced (<104 colony forming units/ml) or no growth of 4 and 57 of these isolates was observed in DC4 and DC-80, respectively. The difference between mean bias of immediate culture and DC4 (-0.035, limits of agreement -0.977 to 0.906) and immediate culture and DC-80 (-1.832, limits of agreement -4.914 to 1.267) was -1.788 +/- 1.682 (P<0.0001). Sensitivity and negative predictive value were 96.5% and 97.8% for DC4 and 50.4% and 75.4% for DC-80, respectively; the differences were statistically significant (P<0.0001).
Bronchoalveolar lavage samples can be processed for culture when stored up to 24 hours at 4degreesC without loss of diagnostic accuracy. Delayed culturing after storage at -80 degrees C may be not reliable, in particular with regard to Gram-negative bacteria.
Critical care (London, England) 07/2013; 17(4):R135. DOI:10.1186/cc12814
[Show abstract][Hide abstract] ABSTRACT: PURPOSE: Changes in electrolyte homeostasis are important causes of acid-base disorders. While the effects of chloride are well studied, only little is known of the potential contributions of sodium to metabolic acid-base state. Thus, we investigated the effects of intensive care unit (ICU)-acquired hypernatremia on acid-base state. METHODS: We included critically ill patients who developed hypernatremia, defined as a serum sodium concentration exceeding 149 mmol/L, after ICU admission in this retrospective study. Data on electrolyte and acid-base state in all included patients were gathered in order to analyze the effects of hypernatremia on metabolic acid-base state by use of the physical-chemical approach. RESULTS: A total of 51 patients were included in the study. The time of rising serum sodium and hypernatremia was accompanied by metabolic alkalosis. A transient increase in total base excess (standard base excess from 0.1 to 5.5 mmol/L) paralleled by a transient increase in the base excess due to sodium (base excess sodium from 0.7 to 4.1 mmol/L) could be observed. The other determinants of metabolic acid-base state remained stable. The increase in base excess was accompanied by a slight increase in overall pH (from 7.392 to 7.429, standard base excess from 0.1 to 5.5 mmol/L). CONCLUSIONS: Hypernatremia is accompanied by metabolic alkalosis and an increase in pH. Given the high prevalence of hypernatremia, especially in critically ill patients, hypernatremic alkalosis should be part of the differential diagnosis of metabolic acid-base disorders.
Intensive Care Medicine 11/2012; 39(3). DOI:10.1007/s00134-012-2753-3 · 7.21 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Hypoxic hepatitis (HH) is a form of hepatic injury following arterial hypoxemia, ischemia, and passive congestion of the liver. We investigated the incidence and the prognostic implications of HH in the medical intensive care unit (ICU).
A total of 1,066 consecutive ICU admissions at three medical ICUs of a university hospital were included in this prospective cohort study. All patients were screened prospectively for the presence of HH according to established criteria. Independent risk factors of mortality in this cohort of critically ill patients were identified by a multivariate Poisson regression model.
A total of 118 admissions (11%) had HH during their ICU stay. These patients had different baseline characteristics, longer median ICU stay (8 vs. 6 days, p < 0.001), and decreased ICU survival (43 vs. 83%, p < 0.001). The crude mortality rate ratio of admissions with HH was 4.62 (95% CI 3.63-5.86, p < 0.001). Regression analysis demonstrated strong mortality risk for admissions with HH requiring vasopressor therapy (adjusted rate ratio 4.91; 95% CI 2.51-9.60, p < 0.001), whereas HH was not significantly associated with mortality in admissions without vasopressor therapy (adjusted rate ratio 1.79, 95% CI 0.52-6.23, p = 0.359).
Hypoxic hepatitis (HH) occurs frequently in the medical ICU. The presence of HH is a strong risk factor for mortality in the ICU in patients requiring vasopressor therapy.
Intensive Care Medicine 06/2011; 37(8):1302-10. DOI:10.1007/s00134-011-2248-7 · 7.21 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Hypoxic hepatitis (HH) is a frequent cause of acute hepatocellular damage at the intensive care unit. Although mortality is reported to be high, risk factors for mortality in this population are unknown.
One-hundred and seventeen consecutive patients with HH were studied prospectively at three medical intensive care units of a university hospital.
The main causes of hypoxic hepatitis were low cardiac output and septic shock, and most patients (74%) had more than one underlying factor. Peak aspartate transaminase (P = 0.02), lactate dehydrogenase (P = 0.03), INR (P < 0.001) and lactate (P < 0.01) were higher in non-survivors. Prolonged duration of HH caused higher overall mortality rate (P = 0.03). INR > 2 (P = 0.02), septic shock (P = 0.01) and SOFA score >10 (P = 0.04) were risk factors of mortality in the regression model.
Hypoxic hepatitis is the consequence of multiorgan injury. Outcome is influenced by the severity of liver impairment and the etiology and severity of the basic disease.
Intensive Care Medicine 06/2009; 35(8):1397-405. DOI:10.1007/s00134-009-1508-2 · 7.21 Impact Factor