Marcus Pohl

Die mechanische Beatmung ist ein Grundpfeiler der intensivmedizinischen Behandlung kritisch-kranker Patienten. Bei der Mehrzahl der Patienten kann die akute Erkrankung geheilt oder wesentlich gelindert werden. Bei einem kleinen Teil der Patienten entwickelt sich jedoch aufgrund der Schwere der akuten Erkrankung oder Verletzung, der vorbestehenden Komorbidität und der Folgeerkrankungen eine Langzeitabhängigkeit von intensivmedizinischer Technologie. Ziel der Behandlung bei diesen chronisch kritisch-kranken Patienten ist die weitestgehende Wiederherstellung der körperlichen, mentalen und emotionalen Fähigkeiten.

Das auf einer Intensivstation (ITS) erworbene Schwächesyndrom findet sich häufig bei Patienten, die länger als geplant auf Intensivstation behandelt werden müssen. Kommen zu der akuten schweren Erkrankung Risikofaktoren wie eine Sepsis, Immobilisation, Störungen im Glukosestoffwechsel mit Hyperglykämie, die Therapie mit Glukokortikoiden und die Gabe von neuromuskulären Blockern, steigt die Wahrscheinlichkeit, an einem auf ITS-erworbenen Schwächesyndrom zu erkranken. Dabei resultiert das ITS-erworbene Schwächesyndrom aus mindestens drei verschiedenen Funktionsstörungen, die isoliert oder überlappend auftreten können und klinisch selten voneinander abgrenzbar sind: erstens der Critical-Illness-Polyneuropathie (CIP), zweitens einer Critical-Illness-Myopathie (CIM) und drittens einer Störung der neuromuskulären Überleitung. Die CIP und die CIM werden bei Intensivpatienten am häufigsten nachgewiesen.

Background: Stage I of a preplanned 2‐stage study has provided good evidence for improved glycemic control with a disease‐specific enteral formula low in carbohydrates and high in monounsaturated fatty acids (MUFAs), fish oil, chromium, and antioxidants in insulin‐treated type 2 diabetes. The study was continued with stage II to give confirmatory proof of these beneficial effects. Methods: 105 patients with HbA_1C ≥ 7.0% and/or fasting blood glucose (FG) > 6.7 mmol/L (>120 mg/dL) requiring enteral tube feeding due to neurological dysphagia received 113 kJ (27 kcal)/kg body weight of either test formula (Diben) or an isoenergetic, isonitrogenous standard formula (control) for up to 84 days. Total insulin (TI) requirements, FG, and afternoon blood glucose (AG) were assessed daily. HbA_1C and safety criteria were evaluated on days 1, 28, 56, and 84. Results: 55 patients completed the study; on day 84, median changes from baseline (data as available, test vs control) were the following: TI,– 8.0 vs +2.0 IU; FG, –2.17 vs –0.67 mmol/L (–39.0 vs– 12.1 mg/dL); HbA_1C, –1.30% vs –1.20%; AG,– 2.36 vs –0.49 mmol/L (–42.5 vs –8.9 mg/dL). The number of relevant hypoglycemic episodes (FG < 3.33 mmol/L < 60 mg/dL) was 1 vs 5. Feeding tolerance was comparable in both groups. Conclusions: Long‐term tube feeding with a disease‐specific enteral formula was safe and well tolerated in type 2 diabetic patients with neurological disorders. When compared with a standard diet, TI requirement decreased significantly with less hypoglycemia whereas FG and AG were significantly lowered, resulting in improved glycemic control.

Primary objective: The aim of the present study was to evaluate the association of contractures with an increase or reduction of non-spastic muscle overactivity due to severe cerebral damage. Methods and procedures: Forty-five patients with tetraparesis after severe cerebral damage were investigated. Three groups were defined based on the presence of spasticity (revealed as resistance to passive stretch (= hypertonia)), and the presence of contracture of the relevant knee joint: Group_s(17 patients with hypertonia without contracture), Group_s+c(20 patients with hypertonia and contracture), and Group_c(eight patients without hypertonia and with contracture). In all groups spontaneous involuntary muscle activity was assessed continuously over a 12-hour period through isometric measurement of knee joint flexion torque. A mathematical algorithm differentiated an hourly muscle activity spectrum (PI_h). The frequency of peaks (peaks_h) from the activity spectrum was determined. Main outcomes and results: We revealed that Group_shad higher PI_hand more frequent peaks_hcompared with Group_s+cand Group_c(p < 0.05). Group_chad comparable PI_hand peaks_hcompared with Group_s+c(p > 0.05). Conclusion: The presence of contractures was associated with lower involuntary muscle overactivity in terms of lower PI_hand less frequent peaks_h, indicating that contractures may be associated with reduced non-spastic positive features of the upper motor neurone syndrome in patients with severe brain damage.

Objective: To evaluate the immediate effects of individually designed functional in-shoe ankle-foot orthoses (AFO) made of soft and hard cast on balance, standing, and gait parameters in hemiparetic patients. Design: Crossover design with randomized order of the intervention. Setting: A rehabilitation centre for adults with neurological disorders. Subjects: Twenty-eight patients with hemiparesis due to stroke or traumatic brain injury. Measures: Postural sway, standing and gait parameters based on ground reaction forces in two conditions: Patients were randomly assigned to varying sequences of wearing AFO in footwear or wearing footwear alone. Results: AFO significantly improved weight-bearing on the affected leg (affected/ unaffected side symmetry: 2.259 ± 1.5 with AFO versus 3.49 ± 2.5 without AFO, P B ± 0.05) and postural sway in stance (12.5 mm9 ± 5.2 with AFO versus 15.7 mm9 ± 6.7 without AFO, P < ± 0.05), double stance duration (21.19 ± 14.4% of gait cycle with AFO versus 25.99 ± 21.6% of gait cycle without AFO, P < ± 0.05), and symmetry ratios of gait parameters such as stance duration (2.09 ± 1.5 s with AFO versus 3.39 ± 3.6 s without AFO, P < ± 0.05) and deceleration forces (1.69 ± 0.5 with AFO versus 1.99 ± 0.6 without AFO, P < ± 0.05) during gait. No significant differences were observed in all other symmetry ratios of gait parameters. Conclusion: An individually designed functional in-shoe AFO can improve stance and gait parameters, even in a single use, in patients with hemiparesis.

Objectives: Design: Setting: Subjects: Interventions: Results: Conclusions: Sponsorship: