‚Intensive care unit-acquired weakness‘ und neuromuskulärer Ultraschall

Die Anaesthesiologie -     

Versorgungsforschung in der Intensivmedizin in Deutschland

Die Anaesthesiologie - Die Versorgungsforschung (VF) ist ein fachübergreifendes multidisziplinäres Forschungsgebiet, das die Kranken- und Gesundheitsversorgung sowie ihre...     

Adjunctive therapies in severe sepsis and septic shock: Current place of steroids

For more than five decades, the use of corticosteroids as an adjunctive therapy to treat severe sepsis and septic shock has incited consistent debate. Negative results of the Corticosteroid Therapy of Septic Shock (CORTICUS) study evoked a revision of Surviving Sepsis Campaign guidelines suggesting a more restricted use of low-dose hydrocortisone only in patients with severe septic shock. Hemodynamic improvement by low-dose steroids was evident and independent from adrenal insufficiency, but did not improve survival. The roles of cortisol measurement and adrenal function tests for treatment decisions have been questioned. An international task force introduced the concept of critical illness-related corticosteroid insufficiency, which challenges the predominant role of adrenal dysfunction and underscores sustained inflammation due to tissue steroid resistance. Whether moderate steroid doses induce superinfections and muscle weakness is unclear. This article reviews recent publications, actual recommendations, ongoing discussions, and future perspectives.     

Social support during intensive care unit stay might improve mental impairment and consequently health-related quality of life in survivors of severe acute respiratory distress syndrome

Introduction  

We investigated health-related quality of life (HRQoL) and persistent symptoms of post-traumatic stress disorder (PTSD) in long-term survivors of acute respiratory distress syndrome (ARDS). We wished to evaluate the influence of PTSD on HRQoL and to investigate the influence of perceived social support during intensive care unit (ICU) treatment on both PTSD symptoms and HRQoL.     

Lungenprotektive Strategien zur Therapie des ARDS

Gegenstand dieser übersicht ist die kritische Darstellung verschiedener Aspekte der bisherigen Forschung zum beatmungsinduzierten Lungenschaden. Im Einzelnen werden die verschiedenen Pathomechanismen, die zum beatmungsinduzierten Lungenschaden führen k?nnen, wie z. B. „mechanischer Scher-Stress“ oder die Freisetzung proinflammatorischer Zytokine dargestellt. Ergebnisse prospektiv-kontrollierter, randomisierter Studien zu den Effekten kontrollierter Beatmung auf die Progression eines Lungenschadens sowie die daraus resultierenden, klinischen Empfehlungen für die Beatmungsstrategien bei Patienten mit schwerem, akuten Lungenversagen werden als übersicht aufgezeigt. Darüber hinaus wird der Stellenwert adjuvanter Therapiema?nahmen, wie der Inhalation von Stickstoffmonoxid oder der Applikation von exogenem Surfactant zur Lungenprotektion er?rtert.     

The E3 ubiquitin ligase TRIM62 and inflammation-induced skeletal muscle atrophy

Introduction

ICU-acquired weakness (ICUAW) complicates the disease course of critically ill patients. Inflammation and acute-phase response occur directly within myocytes and contribute to ICUAW. We observed that tripartite motif–containing 62 (TRIM62), an E3 ubiquitin ligase and modifier of inflammation, is increased in the skeletal muscle of ICUAW patients. We investigated the regulation and function of muscular TRIM62 in critical illness.

Methods

Twenty-six critically ill patients with Sequential Organ Failure Assessment scores ≥8 underwent two skeletal muscle biopsies from the vastus lateralis at median days 5 and 15 in the ICU. Four patients undergoing elective orthopedic surgery served as controls. TRIM62 expression and protein content were analyzed in these biopsies. The kinetics of Trim62, Atrogin1 and MuRF1 expression were determined in the gastrocnemius/plantaris and tibialis anterior muscles from mouse models of inflammation-, denervation- and starvation-induced muscle atrophy to differentiate between these contributors to ICUAW. Cultured myocytes were used for mechanistic analyses.

Results

TRIM62 expression and protein content were increased early and remained elevated in muscles from critically ill patients. In all three animal models, muscular Trim62 expression was early and continuously increased. Trim62 was expressed in myocytes, and its overexpression activated the atrophy-inducing activator protein 1 signal transduction pathway. Knockdown of Trim62 by small interfering RNA inhibited lipopolysaccharide-induced interleukin 6 expression.

Conclusions

TRIM62 is activated in the muscles of critically ill patients. It could play a role in the pathogenesis of ICUAW by activating and maintaining inflammation in myocytes.

Trial registration

Current Controlled Trials ID: ISRCTN77569430 (registered 13 February 2008)

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-014-0545-6) contains supplementary material, which is available to authorized users.     

Bolus or continuous hydrocortisone – that is the question

Constantly evolving treatment guidelines based on a growing body of randomized controlled trials are helping us to improve outcomes in sepsis. However, it must be borne in mind that proven benefit from individual sepsis treatments does not guarantee synergistic beneficial effects when new treatments are added to sepsis management. Indeed, unexpected harmful interactions are also possible. A good example of this is the conflict between intensive insulin therapy and 'low dose' hydrocortisone in septic shock. The goal of tight glycaemic control is made more complicated by steroid-induced hyperglycaemia. In their recent study, Loisa and coworkers demonstrate a measure that reduces the risk for this interaction. They found continuous infusion of hydrocortisone to be associated with fewer hyperglycaemic episodes and reduced staff workload compared with bolus application.     

Gastrointestinal zygomycosis caused by Mucor indicus in a patient with acute traumatic brain injury.

We report a gastrointestinal infection caused by Mucor indicus in a patient with severe head injuries. Monotherapy with high-dose liposomal amphotericin B successfully eradicated the mucormycosis. Nevertheless, subsequently a hemicolectomy was necessary due to recurrent bleeding from a deep ulcer. Mucor indicus is an uncommon fungal pathogen, typically found in starters used for food fermentation. Reviewing other reports on Mucor indicus infections, primary gastrointestinal manifestations seem to be typical and indicate an oral route of infection.