Michael Meisner

Einleitung: Ende 2004 wurden die Empfehlungen zur präoperativen Flüssigkeitskarenz von 6 auf 2 Stunden vor Narkoseeinleitung bei elektiven Eingriffen liberalisiert. Ziel der vorliegenden Studie war eine Beurteilung der neuen Regelung aus Sicht des Patienten und die Überprüfung der Praktikabilität der neuen Empfehlung in der klinischen Praxis. Patienten und Methodik: In einer offenen, randomisierten Studie wurden bei elektiven gynäkologischen Laparoskopien unter standardisierten Narkosebedingungen Patienten mit langer Nüchternheitsperiode (Gruppe LN; Flüssigkeits- und Nahrungskarenz präoperativ ab 0 Uhr des Operationstages) und kurzer Nüchternheitsperiode (Gruppe KN; Nahrungsaufnahme bis 0 Uhr, Flüssigkeitsaufnahme in Form von Pfrimmer Nutricia preOP® bis 2 Stunden vor dem geplanten Eingriff) hinsichtlich verschiedener Parameter des prä- und postoperativen Befindens verglichen. Weiterhin wurden das gastrale Residualvolumen, hämodynamische Parameter und die aktuellen Nüchternzeiten beider Gruppen erfasst. Ergebnisse: 42 Patientinnen konnten in die Studie eingeschlossen werden (Gruppe LN, n = 23, Gruppe KN, n = 19). Beide Gruppen unterschieden sich nicht hinsichtlich ihrer demografischen Daten, Hämodynamik, Operationsdauer sowie dem gastralen Residualvolumen. Die Nahrungskarenz war zwischen den Gruppen vergleichbar mit im Median 11,26 h in der LN und 10,91 h in der KN-Gruppe. Dahingegen war die Zeit der Flüssigkeitskarenz mit 4,53 h in der KN-Gruppe signifikant kürzer als in der LN-Gruppe mit 11,26 h. Signifikant niedrigere Scores wurden präoperativ für das Befinden „Kältegefühl / Frieren” und prä- sowie postoperativ für „Mundtrockenheit / Durstgefühl” in der KN-Gruppe beobachtet. Zusammenfassung: Die Liberalisierung der Flüssigkeitskarenzzeit auf bis zu 2 Stunden vor Narkoseeinleitung mittels freier oraler Zufuhr einer kohlenhydrathaltigen Lösung kann das präoperative Auftreten der Symptome „Kältegefühl / Frieren” sowie das prä- und postoperative Auftreten der Symptoms „Mundtrockenheit / Durstgefühl” bei Patientinnen mit elektiven gynäkologischen Laparoskopien signifikant senken. Dabei liegt in der Praxis die tatsächlich eingehaltene Zeit der Karenz oft über den empfohlenen 2 Stunden. Introduction: In this study, the recently liberalised national guidelines for preoperative fasting were evaluated from the view point of the patients and according to their clinical usability. Patients and Methods: Patients undergoing elective laparoscopic gynaecological surgery were randomised into two groups. Patients in the long-time NPO-group (LTNPO-group) had nothing per mouth after midnight whereas patients in the short-time NPO-group (STNPO-group) did not receive any oral nutrition after midnight but were allowed an unlimited intake of Pfrimmer Nutricia preOP® up to 2 hours before scheduled surgery. Patients were asked to assess the incidence of 12 symptoms of perioperative discomfort prior to and 4–6 hours after surgery using a standardised questionnaire. Gastric fluid volume, vital signs during the induction period of anaesthesia and the actual duration of fasting were registered and compared. Results: 42 patients were included into the study (LTNPO-group: n = 23, STNPO-group: n = 19). The actual duration of fasting for solid nutritition was 11.3 h in the LTNPO-group and 10.9 h in the STNPO-group, respectively. The time of fasting for fluids was in the STNPO-group significantly shorter (4.5 h) compared to the LTNPO-group (11.3 h). The patients of the STNPO-group reported preoperatively a significant lower incidence of “feeling cold” and pre- and postoperatively of “thirst / having a dry mouth”. No significant differences were reported between the groups with respect to heart rate, blood pressure, gastric volume, need of vasopressors and infusion requirements. Discussion: The liberation of the national guidelines for preoperative fluid administration with unlimited intake of a carbohydrate drink offers the benefit of a significantly lower incidence of the preoperative item “feeling cold” and of the pre- and postoperative item “thirst / having a dry mouth”. However, in daily clinical practice the length of fasting for fluids was conspicuously longer than that postulated by the new recommendations.

Objective This study aimed to investigate the correlation of midregional pro-atrial natriuretic peptide (MR-proANP) with severity of septic status in patients with ventilator-associated pneumonia (VAP) and the usefulness of MR-proANP for mortality prediction in VAP. Design Prospective observational cohort study. Setting University Hospital. Patients Seventy-one patients consecutively admitted to ICU who developed VAP. Patients were followed for 28 days after diagnosis, when they were considered survivors. There were no interventions. Results MR-proANP levels increased from sepsis to severe sepsis and septic shock on D0 and D4 of VAP (0.002 and 0.02 respectively). Median MR-proANP levels on day 0 and day 4 (pmol/L [interquartile range]) were 149.0 (79.8–480.0) and 249.0 (93.6–571.0) in septic patients, 438.5 (229.3–762.0) and 407.5 (197.8–738.0) in severe sepsis, 519.5 (369.5–1282.3) and 632.0 (476.0–1047.5) in septic shock. On day 0 and day 4, MR-proANP levels were significantly higher in non-survivors (525.0 [324.0–957.8] and 679.5 [435.0–879.5], respectively) than in survivors (235.0 [102.0–535.0] and 254.0 [110.0–571.0], respectively; P = 0.004). Univariate logistic regression model for mortality included age, gender, APACHE II score, creatinine, logarithmic transformed MR-proANP (LnMR-proANP). Mortality was directly related to LnMR-proANP on D0 and D4, with odds ratios (OR) of 2.06 (95% CI 1.21–3.51) and 2.63 (1.33–5.23), respectively. In multivariate logistic regression, only LnMR-proANP D0 with OR = 2.35 (1.05–5.26) and LnMR-proANP D4 with OR = 3.76 (1.39–10.18) remained significant. Conclusions Our data demonstrated that MR-proANP levels increase progressively with the severity of sepsis and are independent predictors of mortality in VAP.

Background: The present study sought to investigate the correlation of copeptin with the severity of septic status in patients with ventilator-associated pneumonia (VAP), and to analyze the usefulness of copeptin as a predictor of mortality in VAP. Methods: The prospective observational cohort study was conducted in a teaching hospital. The subjects were 71 patients consecutively admitted to the intensive care unit from October 2003 to August 2005 who developed VAP. Copeptin levels were determined on day 0 and day 4 of VAP. Patients were followed for 28 days after the diagnosis, when they were considered survivors. Patients who died before day 28 were classified as nonsurvivors. There were no interventions. Results: Copeptin levels increased from sepsis to severe sepsis and septic shock both on day 0 and day 4 (P = 0.001 and P = 0.009, respectively). Variables included in the univariable logistic regression analysis for mortality were age, gender, Acute Physiology and Chronic Health Evaluation II score and ln copeptin on day 0 and day 4. Mortality was directly related to ln copeptin levels on day 0 and day 4, with odds ratios of 2.32 (95% confidence interval, 1.25 to 4.29) and 2.31 (95% confidence interval, 1.25 to 4.25), respectively. In a multivariable logistic regression model for mortality, only ln copeptin on day 0 with odds ratio 1.97 (95% confidence interval, 1.06 to 3.69) and ln copeptin on day 4 with odds ratio 2.39 (95% confidence interval, 1.24 to 4.62) remained significant. Conclusion: Our data demonstrate that copeptin levels increase progressively with the severity of sepsis and are independent predictors of mortality in VAP.

Introduction: This study sought to assess the prognostic value of the kinetics of procalcitonin (PCT), C-reactive protein (CRP) and clinical scores (clinical pulmonary infection score (CPIS), Sequential Organ Failure Assessment (SOFA)) in the outcome of ventilator-associated pneumonia (VAP) at an early time point, when adequacy of antimicrobial treatment is evaluated. Methods: This prospective observational cohort study was conducted in a teaching hospital. The subjects were 75 patients consecutively admitted to the intensive care unit from October 2003 to August 2005 who developed VAP. Patients were followed for 28 days after the diagnosis, when they were considered survivors. Patients who died before the 28th day were non-survivors. There were no interventions. Results: PCT, CRP and SOFA score were determined on day 0 and day 4. Variables included in the univariable logistic regression model for survival were age, Acute Physiology and Chronic Health Evaluation (APACHE) II score, decreasing ΔSOFA, decreasing ΔPCT and decreasing ΔCRP. Survival was directly related to decreasing ΔPCT with odds ratio (OR) = 5.67 (95% confidence interval 1.78 to 18.03), decreasing ΔCRP with OR = 3.78 (1.24 to 11.50), decreasing ΔSOFA with OR = 3.08 (1.02 to 9.26) and APACHE II score with OR = 0.92 (0.86 to 0.99). In a multivariable logistic regression model for survival, only decreasing ΔPCT with OR = 4.43 (1.08 to 18.18) and decreasing ΔCRP with OR = 7.40 (1.58 to 34.73) remained significant. Decreasing ΔCPIS was not related to survival (p = 0.59). There was a trend to correlate adequacy to survival. Fifty percent of the 20 patients treated with inadequate antibiotics and 65.5% of the 55 patients on adequate antibiotics survived (p = 0.29). Conclusion: Measurement of PCT and CRP at onset and on the fourth day of treatment can predict survival of VAP patients. A decrease in either one of these marker values predicts survival.

Objective. Type and frequency of postoperative abnormalities were registered after cardiovascular surgery to evaluate the aetiology and diagnostic value of increased concentrations of procalcitonin (PCT) and C-reactive protein (CRP) during the early postoperative period. Design. Prospective, observational study. Patients. Two hundred and eight patients undergoing coronary artery bypass grafting or valve replacement requiring cardiopulmonary bypass were monitored for 7 days postoperatively for various types of infectious or non-infectious complications. Plasma PCT and CRP levels were measured on day 1 and day 2 after surgery and, when increased, until day 7. Results. More patients with PCT above 2 ng/ml on day 1 or 2 (n=55) had postoperative abnormalities (95%) than patients with lower PCT (59%). Specifically, the incidence of three or more criteria of the "systemic inflammatory response syndrome" was 45% versus 4% (area under the curve of the receiver operating characteristic 0.866); positive inotropic support was needed in 65% versus 9% (0.870); respiratory insufficiency (PaO₂/FIO₂Conclusions. Elevated PCT, but not CRP, correlates with evidence of systemic inflammation and other complications early postoperatively after cardiac surgery. Although the PCT levels do not rise as quickly as the criteria of the systemic inflammatory response syndrome appear, they do reflect systemic inflammation. Early identification and quantification of a systemic inflammatory response may help reduce postoperative complications.

A self-developing solid-phase immunoassay (B.R.A.H.M.S. PCT-Q, B.R.A.H.M.S.-Diagnostica GmbH, Hennigsdorf, Germany) has recently become available for the semi-quantitative and rapid measurement of procalcitonin (PCT). In this study we examined the validity of this assay at daily clinical routine conditions at five different hospitals in a prospective study.After development of the assay (200 μl plasma, 30 minutes incubation), PCT levels were categorized into four groups (< 0.5 μg/l; ≥ 0.5−< 2 μg/l; ≥ 2−< 10 μg/l; ≥ 10 μg/l) according to the provided reference scale. Samples from patients with suspected elevation of PCT of different etiology (n=237) were read by various analyzers and compared with the results of the Lumitest^®PCT (B.R.A.H.M.S.-Diagnostica GmbH, Hennigsdorf, Germany).A total of 74.7% of measurements were categorized according to the results of the Lumitest^®PCT, 24.5% were read within the next lower or higher category. Using a ± 10% range at the reference concentrations (20% at 0.5 μg/l), 82.7% of samples were correctly categorized and 16.4% within the next categories. Using a cut-off value of 2.0 μg/l, 92.0% (94.1% for ± 10%) of the results were correctly categorized.The semi-quantitative solid phase immunoassay allows a rapid, simple and semi-quantitative measurement of plasma PCT. The validity of the test results and its ease of use are sufficient to support acute diagnostic decisions. However, for the follow-up of PCT concentrations and routine daily measurements, the quantitative luminometric assay should be preferred, when available.