Nierenersatztherapie auf der Intensivstation

Despite improvements in intensive care medicine and renal replacement therapy, acute renal failure in the critically ill patient in the intensive care unit is still associated with a high mortality, independent of the underlying aetiology. In this overview, we address the incidence, consequences, and options for renal replacement therapy. Furthermore, we discuss the timing of initiation of such therapy, patient outcomes with different renal replacement therapies, and the appropriate dialysis dose to be delivered.     

Bronchoskopie auf der Intensivstation

Flexible bronchoscopy is an important diagnostic and therapeutic tool on intensive care unit (ICU) wards and is used to check the correct positioning of the endotracheal tube or to exclude tracheal damage after intubation. Endobronchial bleeding can also be localized and in optimal situations can be stopped. The sensitivity of pathogen diagnostics is also improved by endoscopic interventions. For atelectasis flexible bronchoscopy is needed on the ICU to clear the bronchus from mucus impaction or foreign bodies. New technical equipment allows easier and quicker handling in bedside situations.     

Insulintherapie auf der Intensivstation

Hyperglycemia in patients treated in intensive care units (ICU) with and without known diabetes mellitus is associated with increased mortality and morbidity. Until 2007 the limited evidence from controlled studies and guidelines recommended the following: start insulin treatment when plasma glucose levels are higher than 110?C140?mg/dl (6.1?C7.8?mmol/l) targeting plasma glucose levels of 80?C110?mg/dl (4.4?C6.1?mmol/l). Larger studies and meta-analyses from 2008 onwards showed completely different results. The aggressive insulin treatment showed no beneficial effects on mortality and the largest study (NICE-SUGAR, CMAJ 2009, 180:821?C827) even showed an increased mortality rate compared to moderately treated controls. The morbidity in consideration of severe hypoglycemia was increased in all studies. Therefore scientific societies changed their guidelines from 2009 recommending insulin treatment when plasma glucose levels are higher than 180?mg/dl (10?mmol/l) and targeting plasma glucose levels of 140?C180?mg/dl (7.8?C10?mmol/l). As the prevention of severe hypoglycemia is extremely important only safe insulin protocols should be used. The Yale protocol is one of the safest insulin algorithms and will be presented here in detail.     

Nierenersatztherapie auf der Intensivstation

Background

Acute kidney injury is still one of the most common serious complications in critical ill patients and is associated with high mortality. Even small changes in renal function significantly influence survival and long-term prognosis.

Material and methods

Selective literature research and analysis of intensive care population with renal failure.

Conclusion

Prophylactic measures as well as early diagnosis and therapy must be the goal of a modern intensive care treatment. Various treatment modalities for renal replacement therapy allow individualized treatment of each patient. The review summarizes the main aspects on prophylaxis and early diagnosis of acute kidney injury as well as the different treatment modalities for an individualized renal replacement therapy.     

Antibiotikatherapie auf der Intensivstation

Zusammenfassung Bakterielle Infektionen tragen nach wie vor zu erh?hter Morbidit?t, Mortalit?t und Kostenexplosion auf Intensivstationen bei. Die Antibiotikatherapie auf Intensivstationen wird im allgemeinen empirisch durchgeführt, bis der jeweilige Erreger identifiziert und auf seine Empfindlichkeit getestet wurde. Die Auswahl des geeignetsten Antibiotikums basiert auf allgemeiner und individueller Erfahrung sowie den speziellen Eigenschaften der Substanz und der lokalen Resistenzlage. Meistens wird eine Kombination, bestehend aus einem β-Laktam und einem Aminoglykosid, angewandt. Allerdings kann in vielen F?llen auch eine Monotherapie mit z.B. Ceftazidim, einem Carbapenem, Piperacillin/Tazobactam oder Ciprofloxacin ebenfalls gute Ergebnisse bringen. Wenn mit einer Antibiotikakombination begonnen wurde, sollte die Therapie nach Vorliegen der mikrobiologischen Befunde rasch entsprechend modifiziert und den Erfordernissen der speziellen Situation angepa?t werden. Obwohl Infektionen, die durch h?ufige oder auch seltene Bakterien hervorgerufen werden, in den meisten F?llen problemlos behandelt werden k?nnen, steigt in vielen L?ndern die Anzahl multiresistenter Erreger besorgniserregend an. Multiresistente Enterobakterien, Pseudomonas, Stenotrophomonas, Staphylokokken und Enterokokken werden durch den starken Selektionsdruck gef?rdert. Ma?nahmen zur lokalen Stabilisierung der Resistenzsituation beruhen vor allem auf geeigneten Hygienema?nahmen, um die übertragung multiresistenter Erreger zu verhindern und auf dem verantwortungsvollen Einsatz aller Antibiotika. Eingegangen: 2. Mai 1996 Akzeptiert: 16. Oktober 1996     

Nephrologie auf der Intensivstation

For the treatment of patients with acute kidney injury in the intensive care unit both intermittent and continuous renal replacement therapies (RRT) are used. So far there is no clear evidence that one of these procedures is prognostically superior in terms of mortality; however, results from intervention trials indicated that patient hemodynamic stability and, in particular, recovery of kidney function are more favorable with continuous RRT. Therefore, guidelines now recommend the use of continuous RRT in unstable septic critically ill patients with acute kidney injury. However, due to the high dialysis dose per unit time intermittent RRT is more favorable in cases of severe electrolyte disturbances or intoxication. Nevertheless, intermittent and continuous RRT should not be considered as competitive but rather as two options enabling RRT to be adapted to individual needs with respect to different indications. The dose of RRT seems to have only a limited effect on the prognosis but should be at least 20–25 ml/min/kg body weight in continuous RRT, and should reach at least a weekly Kt/V of 3.9 with intermittent RRT at least 3 times per week. In randomized controlled trials, higher doses of RRT did not have an impact on survival. Finally, regional anticoagulation with citrate results in longer filter circuit life and less bleeding complications compared to anticoagulation with heparin.     

Septische Patienten auf der Intensivstation

Ohne Zusammenfassung     

Akutes Nierenversagen auf der Intensivstation

The RIFLE classification system has drawn attention to the prognostic importance of acute renal failure in patients in intensive care (ICU). The delay of extracorporeal therapy implies an increased mortality and incidence of end-stage renal disease in surviving patients. The start of renal replacement therapy is based on clinical features and a blood urea nitrogen (BUN) level of about 70 mg/dl is only one of numerous markers. Intensity of renal replacement has often been discussed and currently the aim is 25 ml/kg body weight per hour achieved by continuous therapy or 3 to 4 intermittent treatment sessions per week. No improvement was observed when renal replacement therapy was intensified. Currently schedules of best practice care are being developed as the concept of one size fits all is under discussion.     

Erforderliches Monitoring auf der Intensivstation

Monitoring of the critically ill patient with acute heart failure still remains a special challenge for intensive care physicians. A rapid change of the patients' condition is subject to the underlying disease and even cardiac arrest may occur without preliminary warnings. The continuous monitoring of heart rate and rhythm, as well as noninvasive measurement of blood pressure, body temperature and urine elimination are obligatory components of the so-called standard monitoring. In addition, the modular concepts of the present-day monitoring systems become endorsed by techniques such as twelve-lead electrocardiogram and the obligatory echocardiography. Moreover, determination of biochemical markers depends on the clinical problem. The indications for invasive cardiovascular hemodynamic monitoring with pulmonary artery catheter or with less invasive techniques--such as pulse contour analysis or thermal dye dilution technique--must be placed critically. There is no evidence at all that prognosis is changed by implementation of a monitoring technique.     

Resistente Erreger auf der Intensivstation

Antibiotic-resistant pathogens causing healthcare-associated infections pose an increasing public health challenge. Intensive care units represent a center for their generation, selection, and transmission due to the increased morbidity of patients, the increasing number of invasive procedures, inappropriate antibiotic usage, and non-compliance with standard infection control practices. This problem is made more complex because of varying levels of antibiotic resistance depending on the type of healthcare facility, the geographic area, differences between the individual resistant pathogens, and the difficulties associated with detecting some resistance mechanisms. While MRSA epidemics have leveled off in Germany, the rate of Gram-negative pathogens becoming resistant, especially those of the ESBL-phenotype, is steadily increasing. Since treatment options are limited, the establishment of improved antibiotic regimens as well as the implementation of cross-transmission prevention strategies is urgently needed. However, all attempts to meet this public health challenge will only work if this matter is prioritized and appropriate levels of resources are allocated and then used efficiently.     

Die Visite auf der Intensivstation

Although ward rounds are one of the most important daily activities in an intensive care unit, there are no established concepts or standards regarding form and content of a ward round. This paper addresses several organizational aspects, such as time and location of a ward round. It describes the composition of a ward round team, the roles of the team members as well as the tasks of a ward round. These reach from all aspects of patient management to organizational tasks, e.g., teaching and maintaining a good communication and safety culture. A well structured ward round from our point of view is one of the most important components of quality management in an intensive care unit.     

Das pulmorenale Syndrom auf der Intensivstation

Pulmonary renal syndrome is an emergency situation in internal medicine, associated with high mortality if not treated adequately. The underlying diseases include mainly the vasculitides associated with antineutrophil cytoplasmatic antibodies – among these mainly Wegener’s granulomatosis and microscopic polyangiitis – and Goodpasture’s syndrome.After having stabilized the hemodynamic and respiratory status of the patient, it is of great importance to identify the underlying disease and exclude a variety of other diseases that can mimic a pulmonary renal syndrome. Besides taking a history and a complete physical examination, X-ray imaging, scanning for auto-immunologic antibodies and bronchoscopy have proved to be helpful for this purpose.In addition, a renal biopsy should be performed if possible. Whether a biopsy of the lung is of further diagnostic value is unclear. Therapy is based on intense immunosuppression and plasmapheresis.     

Plasmapherese und Immunadsorption auf der Intensivstation

Over the last 40 years plasmapheresis technology and its indications for use have been continually evolving. With the growing incidence for autoimmune diseases, unsatisfactory therapeutic options, side-effects of drug therapy, economic relevance and apheresis, clinicians have been tending more towards selective plasmapheresis techniques through the use of immunoadsorption columns. Immunoadsorption is used to target specific disease-producing pathogens for removal during extracorporeal therapy. Evidence is accumulating for the use of plasmapheresis and immunoadsorption in several immune-mediated conditions in critically ill patients. The outlook for some emergencies continues to be desolate, however, and various therapies are used based on evidence from case reports and small case series even if randomized, controlled studies are still lacking for many diseases. The new therapies are relatively safe but careful monitoring is needed, because there is a potential for serious adverse events.     

Antikoagulation bei Nierenersatztherapie auf der Intensivstation

The choice of the form of anticoagulation in continuous renal replacement therapy (CRRT) in critically ill patients often depends on local factors and the individual clinical situation. Heparin is the form of anticoagulation most often used for CRRT for preventing thrombosis in the blood circulation. Critically ill patients have an increased likelihood of bleeding, making sufficient anticoagulation difficult. In cases of suspected or proven heparin-induced thrombopenia (HIT), therapeutic anticoagulation is recommended with direct thrombin inhibitors or danaparoid. Anticoagulation of CRRT can also be conducted with these agents but monitoring in critically ill patients is difficult, giving rise to bleeding complications and short circulation life. In contrast, regional anticoagulation with citrate does not have these disadvantages. Even in cases of HIT or after surgery CRRT can be continued without risk. Modern dialysis devices, adapted dialysates and simple monitoring help to prevent complications such as hypocalcemia or metabolic alkalosis. Therefore, regional anticoagulation with citrate will probably become the standard form of anticoagulation for CRRT in intensive care units.