Early and Rapid Identification of COVID-19 Patients with Neutralizing Type I Interferon Auto-antibodies

Journal of Clinical Immunology - Six to 19% of critically ill COVID-19 patients display circulating auto-antibodies against type I interferons (IFN-AABs). Here, we establish a clinically applicable...     

Einseitige High-Frequency-Jet-Ventilation als Erg?nzung der Ein-Lungenbeatmung bei thoraxchirurgischen Eingriffen

Wir berichten über 2 Patienten, bei denen ein operativer Eingriff an der rechten Lunge zur Entfernung eines Malignoms durchgeführt werden musste. Die linke Lunge wies in beiden F?llen eine erhebliche Funktionseinschr?nkung auf. Beim ersten Patienten war das Volumen dieser Seite infolge einer vor kurzem durchgeführten Oberlappenresektion um etwa die H?lfte verringert, beim zweiten Patienten betrug die Perfusion der linken Lunge nur noch 18% der gesamten Lungendurchblutung. Aufgrund dieser Ver?nderungen hielten wir die konventionelle Ein-Lungenbeatmung für nicht praktikabel und führten die Eingriffe unter seitendifferenter Ventilation durch. Die unten liegende, linke Lunge wurde hierbei mittels intermittierender überdruckbeatmung (IPPV) beatmet, wobei das Tidalvolumen beim ersten Patienten wegen hoher Beatmungsdrücke auf 200 ml reduziert werden musste. Die Beatmung der oben liegenden, rechten Lunge erfolgte in beiden F?llen simultan mittels High-Frequency-Jet-Ventilation (HFJV). Die arterielle O₂-S?ttigung lag hierunter zwischen 96 und 100%, der arterielle CO₂-Partialdruck betrug jeweils 45 mmHg. Der operative Ablauf wurde durch die Beatmung nicht behindert, die postoperativen Verl?ufe waren ebenfalls komplikationslos. Die Fallbeispiele zeigen, dass man mit Hilfe des dargestellten Beatmungsregimes (operierte Seite: HFJV, nichtoperierte Seite: IPPV) auch solche Patienten mit Erfolg an der Lunge operieren kann, bei denen die konventionelle Ein-Lungenbeatmung aus funktionellen Gründen nicht in Betracht kommt.     

What is the benefit of subglottic suction?

Bronchopulmonary infections are the main cause of morbidity and mortality in intensive care wards. Since the usual anatomical and physiological barrier is missing in the intubated patient, oropharyngeal secretion will reach the subglottic space between glottis and upper rim of the low-pressure cuff. Starting from there, continuous microaspiration between cuff and tracheal mucosa leads to bacterial contamination of the upper respiratory tract. In patients with a disturbed immune system from that point on colonization and infection may follow. Therefore one is called upon to search for measures to prevent infection in ventilated patients. Selective decontamination of oropharynx and gastrointestinal tract has been described as an effective method. Others are recommending the application of aminoglycosides in the tracheobroncheal system. Removing retained secreted material is a general surgical principle. Therefore we tested the practicability and effectiveness of a continuous subglottic drainage. At this point we are mainly interested in its clinical aspects and in the method. We investigated the subglottic drainage in 10 intensive care patients who were on long-term mechanical ventilation and had undergone tracheostomy. All patients had an Ultratracheoflex cannula Nr. 9-11 (Rüsch Company, West Germany). It was modified by a suction catheter Ch. 12 (Uno Plast Company, West Germany): We cut two additional small holes in the curved catheter tip and attached the catheter with this part above the cuff at the dorsal convexity to the tracheoflex cannula (see illustration 1). An infusion pump was used for suctioning secretion from the subglottic space by an ordinary infusion set and at a suction flow of 100-125 ml/h.(ABSTRACT TRUNCATED AT 250 WORDS)     

Gibt es eine Indikation zur neoadjuvanten oder adjuvanten Systemtherapie beim Nierenzellkarzinom?

Looking at the most frequent urological tumors kidney cancer has the worst prognosis. Primary therapy consists of operative tumor removal in most cases. A tumor cutoff between 4 and 5 cm represents the turn towards a significant risk for postoperative tumor relapse. In those patients neoadjuvant or adjuvant therapy would be indicated. However, no phase III trials on neoadjuvant therapy of kidney cancer have been published in the literature. In contrast, five phase III trials on adjuvant therapy of kidney cancer have been published. In four trials interferon-α and/or interleukin-2 were applied. None of these trials had a positive outcome. Moreover, adjuvant cytokine therapy was associated with significant side effects in 30% of patients. In the fifth trial an autologous tumor cell vaccine (Reniale®) demonstrated an improvement of progression-free survival and overall survival. Also, there were less than 1% side effects. Results from active trials investigating a combination of interleukin-2, interferon-α and 5-FU, or a heat shock protein vaccine or an antibody are awaited soon. New trials are testing tyrosine kidney inhibitors such as sunitinib and sorafenib.     

Warten auf die Krisis

Aim of the study: Experience in daily routine reveals that most of ICU patients usually go through “crisis” within 14 days of admission. Only few patients need remarkable more time to get to this point and it seems there is hardly anything to be done therapeutically to change the course of it. We therefore examined a large group of ICU patients in order to find reasons for this course or to spot them as an “entity of their own”.Methods: 1,861 ICU patients all being on IPPV for more than three days were included in the study. Every day 18 variables were taken down in a standardised way until the day IPPV was finished. We extracted 170 patients who were artificially ventilated for more than 40 days. For these patients we established mean values for each of the 18 variables during the first and the last 40 days of ventilation. In both groups we compared survivors to non-survivors.Results: Mortality was almost the same in both groups (IPPV <40 days vs. IPPV >40 days). Survivors and non-survivors showed remarkable differences regarding extrapulmonary factors — in terms of total fluid amount and transfusion, state of abdomen, brain, liver and kidney function and circulation problems. Pulmonary factors revealed major differences only towards the end of the observation period.Conclusions: There seems to be an “entity of ist own”, a small population of patients who arrive at the crucial turning point later. Pulmonary complications (pneumonia, ARDS) is not the reason but the expression of cause for prolonged ventilation. The key to the extrapulmonary origin of the crisis remains unknown, the only thing we can do is alleviate its manifestations.     

Postoperative Resistenzentwicklung gegenüber Atracurium

Zusammenfassung Zwei F?lle einer postoperativ aufgetretenen Atracuriumresistenz werden vorgestellt. In beiden F?llen handelte es sich um Patienten, welche nach einem intrathorakalen Elektiveingriff eine septische Komplikation entwickelten. Kasuistik: Beim ersten Patienten (39 Jahre) entwickelte sich wenige Tage nach einer Pneumonektomie eine Bronchusfistel mit einer Superinfektion der Thoraxresth?hle. Zum Zeitpunkt des Revisionseingriffs war die Wirkung von Atracurium im Vergleich zur Prim?roperation deutlich ver?ndert: Die Anschlagzeit war verl?ngert (7 vs. 3,5 min), die Erholungszeit (DUR 10%) war verkürzt (14 vs. 28 min), und die Infusionsrate zur Aufrechterhaltung der Relaxation mu?te um ca. das 3fache gesteigert werden (14,3 vs. 5,0 μg/kg·min). Beim zweiten Patienten (56 Jahre) kam es im Anschlu? an eine Oberlappenresektion rechts zu einer Gangr?n des Mittellappens, welcher operativ entfernt werden mu?te. Die zur Intubation erforderliche Atracuriumdosis mu?te im Vergleich zur Prim?roperation deutlich gesteigert werden (70 vs. 40 mg), ohne da? hierdurch eine komplette neuromuskul?re Blockade zu erzielen war. Darüber hinaus war zur Ruhigstellung des Patienten eine wesentlich h?here Erhaltungsdosis als beim Ersteingriff erforderlich (11,8–16,5 vs. 5,5 μg/kg·min). Schlu?folgerung: Die Beispiele zeigen, da? sich innerhalb relativ kurzer Zeit eine Resistenz gegenüber Atracurium entwickeln kann, und wir nehmen an, da? diese Ver?nderungen durch die schweren, entzündlichen Komplikationen ausgel?st wurden.      

Lärm auf Intensivstationen Ein Beitrag zur Lärmreduktion durch Modifikation der Atemgasbefeuchtung

Today, noise pollution is an evident and ubiquitous problem even in intensive care units. Noise can disturb the physiological and psychological balance in patients and staff. Especially intubated patients and those breathing spontaneously through a T-piece are exposed to the noise emitted by the nebuliser used to humidity the respiratory gas. This may make patients feel uncomfortable. To reduce noise pollution in the ICU a modified T-piece has been developed and investigated. In order to heat and humidity the respiratory gas a Conchaterm III unit (Kendall company) and a thermo flow cylinder (De Vilbiss company) is necessary. While respiratory gas is flowing, water is sucked out of the heated thermoflow cylinder and nebulised according to the Venturi-Bernoulli principle. To adjust the oxygen concentration of the respiratory gas a plastic ring must be turned to either close (98% oxygen) or open a valve allowing room air to mix (40% oxygen). Noise pollution of the unit varies with admixture of room air. With a new device – a special oxygen – air mixing chamber – the oxygen concentration of the respiratory gas can be adjusted outside the thermoflow cylinder, hardly producing any noise pollution. Therefore the principle of nebulisation could be changed to humidification. A thermoflow cylinder without the nebulisation unit allows the respiratory gas to flow through the thermoflow cylinder over heated and evaporating water, hardly causing any noise pollution. In both types of T-pieces the temperature of the respiratory gas is controlled and corrected by the Conchaterm unit. As the result of these modifications, noise pollution has been reduced from 70?dB(A) to 55?dB(A). In the modified T-piece, the quality of humidification has been evaluated with a fresh gas flow of 22?l/min and at a gas temperature of 37°?C, not only collecting condensed water but also lost water. The modified T-piece allows a physiological humidification of the respiratory gas. The modified T-piece is a simple and efficacious substitute. Patients and staff are protected from adverse noise effects and patient well-being might be improved.