Prognose und Monitoring bei akuter Pankreatitis

Acute pancraetitis is a potentially life-threatening disorder with increasing incidence. Early diagnosis and therapy of severe/necrotizing pancreatitis with a mortality of 15–42% is of paramount importance. By contrast, mild/edematous pancreatitis has a mortality below 1%. Prediction of severity as well as prognosis are further impeded by a marked time dependency of the prognostic value of the different predictors. Therefore, exact determination of the onset of symptoms (pain) is highly relevant. Depending on the time that the symptoms started, at least three prognostic scenarios with different values of prognostic markers have to be taken into account. Regarding the first presentation/emergency room scenario, several “simple” parameters have high prognostic value: early presentation (within <24 h after the onset of symptoms), increased blood glucose, increased hematocrit, and increased blood urea nitrogen (BUN) have been demonstrated to be predictors with high sensitivity and high negative predictive value, but low specificity and low positive predictive value. Patients fulfilling at least one of these criteria should be transferred to the ICU, although not all of these patients will develop severe/necrotizing pancreatitis. After 48 h (early re-evaluation scenario), the APACHE-II score (cut-off >8), the Ranson score (cut-off >3 points), and a serum CRP level >15 mg/dl have appropriate prognostic accuracy. For the subgroup of patients admitted to an ICU (ICU admission scenario), a specific score has been introduced with arterial pH, age, mean arterial pressure (MAP), and BUN being the most important predictors for mortality. Retrospective analyses at the end of the ICU stay demonstrated an association of mortality with the requirement of renal replacement therapy and minimum levels of serum protein, calcium, and arterial bicarbonate.     

Monitoring und Therapie bei akuter Pankreatitis

Acute pancreatitis is a potentially life-threatening disorder with a rapid course of development; therefore, the time frame for diagnosis and treatment is narrow. Early diagnosis and therapy of severe necrotizing pancreatitis is of paramount importance with a mortality of 15–42?%. In contrast mild edematous pancreatitis has a fatal course in only 1?% of cases. Prediction of severity is impeded by a marked time dependency of the prognostic value of the different predictors; therefore, an exact determination of the onset of pain is highly relevant. At least three prognostic scenarios with different values for prognostic markers have to be taken into account. In the emergency room scenario, several simple parameters have a high prognostic value: increased blood glucose, increased hematocrit and increased blood urea nitrogen (BUN) have been demonstrated to be predictors with high sensitivity and high negative predictive value but low specificity and low positive predictive value. Furthermore, the relatively straightforward bedside index of severity in acute pancreatitis (BISAP) score has been validated to accurately predict prognosis. In the early re-evaluation scenario after 48 h the acute physiology and chronic health examination (APACHE) II score (cut-off 8 points) and the Ranson score (cut-off 3 points) provide high prognostic accuracy. For patients admitted to the intensive care unit (ICU admission scenario) specific markers of organ failure are available. The results of meta-analyses confirm a therapeutic effectiveness with limited effect size for the use of endoscopic retrograde cholangiography in severe biliary pancreatitis particularly in cases of cholangitis, for antibiotics (imipenem) in necrotizing pancreatitis and for early enteral feeding. An association of poor prognosis with increases in BUN and the hematocrit suggests the use of early goal-directed volume replacement which should be tailored to the clinical picture, echocardiography and/or modern hemodynamic parameters instead of central venous pressure which is unsuitable. Severe pain usually requires the use of opioid analgesia. Even when necrosis is present, conservative management (radiologically or endoscopically placed drainage) is appropriate. If these therapeutic approaches are not successful or cannot be managed technically, a surgical step-up should be considered.     

Endoskopische Therapie bei akuter und chronischer Pankreatitis

Endoscopic therapy is valuable for both acute and chronic pancreatitis. Early endoscopic papillotomy appears, in the case of a severe course of acute biliary pancreatitis, to be advantageous. Endoscopic drainage can be considered in cases of acute fluid retention and necrosis as well as subacute, non-healing pancreatitis or cyst development. By acute chronic pancreatitis with strictures or bile duct stones, papillotomy, dilation and stent insertion can lead to an improvement in pain symptoms. An improvement in endo- or exocrine function, however, is not expected. Studies on the endoscopic therapy of pancreatitis are still very limited, and recommendations can usually only be made based on retrospective case series.     

Endoskopische Therapieverfahren bei Adipositas

Bariatric surgery is now an accepted method for treatment of morbid obesity. Weight reduction of patients can be achieved with restrictive and malabsorptive interventions, which are accompanied by a significant reduction in mortality. Because obese patients often have severe comorbidities, interventions are often associated with increased morbidity and mortality. Endoscopic transoral treatment procedures could represent a minimally invasive alternative for treatment of morbid obesity. In placebo-controlled studies only the intragastric balloon has so far been sufficiently studied. It could be demonstrated that this endoscopic procedure only results in a permanent weight reduction within a concept of a consecutive operative treatment. Transoral gastroplasty (TOGA) and the transoral endoscopic restrictive system (TERIS) are new methods for which proof of principle could be demonstrated in initial clinical trials. Malabsorptive endoscopic treatment procedures, in particular the EndoBarrier or gastric sleeve procedure, have rates of undesired side effects which should not be underestimated. The future will show which methods finally gain acceptance and become widespread.     

Interventionelle Therapiestrategien bei resistenter Hypertonie

For some years it has been possible to offer two new interventional treatment options to patients with resistant hypertension, stimulation of the carotid baroreceptors and radiofrequency ablation of the activated renal sympathetic nerve (renal denervation). With the first method the baroreceptors in the carotid sinus are stimulated after prior implantation of electrodes and a programmable pulse generator system. In the second method the renal sympathetic nerve fibers of the renal arteries are severed by minimally invasive catheter-aided radiofrequency ablation. Both therapy options achieve a systolic blood pressure reduction of at least 10?mmHg in 70?C90% of patients. With carotid sinus stimulation the average blood pressure was reduced on average by approximately 30?C35/15?C20?mmHg 12 months after implantation. Comparable data but with a slightly less pronounced tendency, have been published for renal denervation. Contraindications for carotid sinus stimulation are carotid stenosis of more than 50% or large carotid plaques and for radiofrequency ablation of renal sympathetic activity renal artery stenosis or a history of renal artery stenting and additionally patients with an estimated glomerular filtration rate (eGFR) under 45?ml/min.     

Interventionelle Hypertonietherapie bei Diabetes mellitus

Hypertension is the most common chronic cardiovascular disease with increasing prevalence all over the world. Despite the availability of many effective antihypertensive drugs, blood pressure control to target values remains low. In the pathophysiology of therapy resistant hypertension, increased activity of the sympathetic nervous system with an imbalance between sympathetic and parasympathetic activity has been identified as a main contributor to the development and maintenance of hypertension. Catheter-based denervation of the renal sympathetic nerves has been described as reducing blood pressure and decreasing sympathetic activity in patients with resistant hypertension. Supplementary beneficial effects on common cardiovascular comorbidities, such as diabetes type 2, have been reported. The present review aims to give an overview about percutaneous renal denervation for treatment of hypertension and potential new therapeutic options to improve glycemic control.     

Therapie bei chronischer Pankreatitis

The therapy of chronic pancreatitis has recently changed in some major aspects. The therapy of acute episodes does not differ from the therapy of acute pancreatitis. Immediate and adequate fluid therapy is the backbone of the treatment of acute episodes. The general prophylactic administration of antibiotics in necrotizing pancreatitis does not seem to be useful; however, in cases of severe necrotizing pancreatitis administration of carbapenems may reduce the risk of pancreatic or peripancreatic infections. During acute episodes nutrition should be given enterally. Treatment of exocrine insufficiency includes supplementation of pancreatic enzymes. The presence of symptoms is an important decision-making point for pancreatic enzyme supplementation. The initial dosage is 20,000–40,000 lipase units per main meal and 10,000–20,000 for a snack. The dose can be doubled if symptoms do not improve. Therapy of pain follows the WHO guidelines. In some cases endoscopic therapy of pancreatic duct abnormalities can lead to pain relief. Surgical therapy is the best therapy for long-term pain relief. Infected necrosis or infected pseudocysts should initially be treated by conservative means. In cases of failure, endoscopic transgastric or transduodenal intervention should be given preference over an open surgical approach.     

Volumentherapie bei akuter Pulmonalembolie

Ohne Zusammenfassung     

Neue Therapieverfahren bei chronisch-entzündlichen Darmerkrankungen

Inflammatory bowel diseases are most likely caused by an excessive immune reaction to the gut flora in genetically predisposed individuals. This excessive reaction depends on an imbalance of pro- and anti-inflammatory processes. T cells are central effector cells of the immune reaction in inflammatory bowel diseases. Most new substances that will be available for treating Crohn’s disease and ulcerative colitis in the near future target the activation, migration, and effector functions of T helper cells. Other substances currently being evaluated attempt to bolster epithelial defence mechanisms. Clinical remission is still the therapeutic goal in inflammatory bowel diseases. Whether “mucosal healing” can lead to a better prognosis remains a matter of debate.     

Elektrolytverschiebungen bei akuter respiratorischer Alkalose

In acute respiratory alcalosis there is a typical change in acid-base status characterized by a decrease of pCO₂ accompanied by a decrease in H⁺-ion concentration, as well as a typical change in electrolytes. This study was performed to show the extent of the electrolyte change and its reproducibility. The measurements were made (in 39 healthy young adults) before and after 5 min. of maximal voluntary hyperventilation and again after 15, 25 and 35 min. Measured were: pO₂, pCO₂, pH in the arterialized blood of the hyperemisized earlobe; in the plasmafraction of another sample: potassium, sodium, calcium, magnesium, chlorine, anorganic phosphate and total-protein content and in the cellular fraction of the same probe: potassium, sodium and chlorine in the erythrocyte standard bicarbonate-values were determined from the nomogram by Singer & Hastings. The pCO₂ showed a mean decrease of 18 Torr (s=±2,5), the pH rose to a mean value of 7,67 (s=±0,087). The potassium in plasma showed a significant increase (p<0,02) when hyperventilation was finished and a significant decrease (p<0,001) 10 min. after hyperventilation. There was a good correlation (r=0,555) between the increase of pH and the decrease of potassium after hyperventilation. The magnesium concentration in plasma decreased significantly (p<0,001) only during hyperventilation. After that there was no further change, it remained low. There was also a high correlation (r=0,719) between magnesium and pH. Decreases of short duration in standard bicarbonate and anorganic phosphate were also significant (p<0,01). In contrast to other findings it was demonstrated that there is an initial significant increase of potassium in plasma during hyperventilation followed by a significant decrease 10 min. after the end of hyperventilation. The total protein content dropped in each case in a constant manner, although, due to a large standard deviation, no statistical significance was observed. The data showed that the hyperventilation-syndrome is the result of a summation of several electrolyte changes. The results suggested that here the change of calcium seems to be of no importance in the appearance of neuromuscular spasms, but that the decrease of potassium and magnesium seems essentially responsible for an increase of neuro-muscular irritability, and consequently an appearance of spasms.     

Therapeutisches Vorgehen bei akuter Lungenembolie

Zusammenfassung Die Prävalenz der autoptisch gesicherten Lungenembolie (LE) ist ungeachtet der diagnostischen und therapeutischen Fortschritte unverändert hoch. Da die LE einerseits mit einer signifikanten Frühletalität einhergeht und sich die Mortalitätsrate unter einer adäquaten Therapie von ca. 30% auf 2–8% senken lässt, sollte bereits bei Verdacht auf Vorliegen einer LE eine Therapie mit Heparin eingeleitet werden. Bei Patienten mit nicht-massiver LE stehen heute auch niedermolekulare Heparine für die Initialtherapie zur Verfügung. Bei massiver LE mit Schock bzw. Hypotonie ist initial eine systemische Thrombolysetherapie indiziert. Ob hämodynamisch stabile Patienten mit den echokardiographischen Zeichen der rechtsventrikulären Dysfunktion (submassive LE) und/oder erhöhtem Troponin von einer Lysetherapie profitieren, ist derzeit noch Gegenstand kontroverser Diskussion. Als Sekundärprophylaxe wird in der Regel eine Behandlung mit Vitamin-K-Antagonisten durchgeführt.     

Nichtinvasive Beatmung bei akuter respiratorischer Insuffizienz

Zusammenfassung Die nichtinvasive Beatmung über eine Maske erm?glicht bei vielen Patienten eine effiziente Beatmung unter Vermeidung der Risiken und Nebenwirkungen der endotrachealen Intubation. Für die chronisch-obstruktive Lungenerkrankung sind die Vorteile der Maskenbeatmung im Hinblick auf Beatmungsdauer, Dauer der Intensivbehandlung, Prognose und Behandlungskosten inzwischen relativ gut durch Studien belegt. Bei anderen Indikationen erlauben die verfügbaren Daten noch kein gesichertes Urteil, rechtfertigen aber einen Behandlungsversuch auch au?erhalb von Studien in der t?glichen klinischen Routine. Nachteilig sind der tendenziell h?here personelle Betreuungsaufwand bei der nichtinvasiven Beatmung sowie die starke Erfahrungsabh?ngigkeit der Ergebnisse. Die wichtigste Voraussetzung für eine erfolgreiche nichtinvasive Beatmung in der Intensivmedizin ist die Bereitschaft von ?rzten und Pflegepersonal, eine ungewohnte Beatmungsphilosophie zu akzeptieren und die relativ einfache Technik der Maskenbeatmung zu erlernen. Eingegangen: 11. Februar 1999 Akzeptiert: 18. Februar 1999     

Nichtinvasive Beatmung bei akuter respiratorischer Insuffizienz

Non-invasive (NIV) and invasive ventilation are complementary therapies for acute respiratory insufficiency (ARI). As NIV and invasive ventilation relieve the burden on the respiratory muscles with equal efficacy and NIV prevents ventilator-associated pneumonia, NIV should be favored for use in hypercapnic ARI. NIV is recommended as first line therapy in hypercapnic ARI induced by acute exacerbated chronic obstructive pulmonary disease (AECOPD) and it is also reasonably effective in acute ventilatory failure associated with thoracic restriction, neuromuscular disease and severe asthma. Hypoxemic ARI caused by pulmonary or systemic inflammation mostly requires intubation and invasive ventilation for adequate lung recruitment and improvement in pulmonary compliance. Maintaining sufficiently high airway pressures during NIV is a challenge due to mask leakage or disconnection of the interface. When intubation is necessary a delay by NIV may worsen the prognosis suggesting that for non-cardiogenic hypoxemic ARI NIV should only be carried out in centers with experienced teams. In contrast, hypoxemic ARI in cardiogenic lung edema is effectively treated with continuous positive airway pressure (CPAP) or NIV even in out-of-hospital situations.     

Interventionelle Therapie der koronaren Herzkrankheit bei Diabetes mellitus

Cardiovascular diseases often lead to comorbidity, hospitalization and death in patients with diabetes mellitus. Over the last two decades, advances in medication and intervention have led to a reduction in morbidity and mortality. It is more common for diabetic patients to have peri-interventive complications than non-diabetics, and by coronary angioplasty higher rates of recurrence and additional surgery. Peri-interventive risks und re-interventions in diabetics can be reduced to the level of non-diabetics by using recognized medical therapies und interventive treatment strategies. Optimum results following PCI, with a normalization of flow velocity, lead to a reduction in restenosis and re-interventions. Antithrombocytic treatment with glycoprotein IIb/IIIa inhibitors lowers the incidence of peri-interventive complications, re-interventions and mortality. Drug-eluting stents are especially effective in preventing restenosis in diabetics; combined with glycoprotein IIb/IIIa inhibitors, they reduce the re-intervention rate even further. Prior to intervention, patients must be identified as diabetics to select the most suitable treatments.