Publications by authors named "Geraldine de Heer"

18 Publications

  • Page 1 of 1

Are muscle parameters obtained by computed tomography associated with outcome after esophagectomy for cancer?

Clin Nutr 2021 Jun 1;40(6):3729-3740. Epub 2021 May 1.

Department of Intensive Care Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany.

Background & Aims: Esophageal cancer patients often suffer from cancer-related malnutrition and, as a result, sarcopenia. Whether sarcopenia worsens the outcome after esophagectomy is unclear. Inconsistent study results are partly caused by varying cut-off values used for defining sarcopenia. To overcome this challenge, a new statistical approach is proposed in this study: analyzing the linear association of computer tomography derived muscle parameters with important clinical short- and long-term outcomes post esophagectomy, regardless of cut-offs.

Methods: Skeletal muscle index (SMI), quantifying muscle mass, was assessed with computed tomography (CT) in 98 patients undergoing esophagectomy. Muscle radiation attenuation (MRA) was measured to evaluate muscle quality. To evaluate the influence of the SMI and MRA on post-surgery complications, logistic regression models were used. To analyze the relationship of lengths of stay to muscle parameters, the competing risk approach introduced by Fine and Gray was applied. For survival analysis, log-rank test and Cox proportional hazards regression modeling were used.

Results: Neither a relevant association of SMI nor MRA with pneumonia and esophagoenteric leak were observed. Furthermore, no relevant association to lengths of stay in intensive care or hospital were detected. If the SMI increased, the odds for pleural effusion and pleural empyema decreased, but the odds of a pulmonary embolism increased. Univariate, unadjusted long-term survival analysis revealed that lower MRA and lower SMI were associated with shorter survival (P = 0.03). However, if the analysis was adjusted for confounders, e.g., Charlson Comorbidity Index, no relevant association regarding long-term survival was detected.

Conclusion: Consequently, poor muscle status, determined by CT imaging, does not justify denying a patient an oncologic resection. The Charlson Comorbidity Index, however, was superior for preoperative risk stratification.
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http://dx.doi.org/10.1016/j.clnu.2021.04.040DOI Listing
June 2021

Characteristics and Risk Factors for Intensive Care Unit Cardiac Arrest in Critically Ill Patients with COVID-19-A Retrospective Study.

J Clin Med 2021 May 19;10(10). Epub 2021 May 19.

Department of Intensive Care Medicine, University Medical Centre Hamburg-Eppendorf, 20246 Hamburg, Germany.

The severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) causing the coronavirus disease 2019 (COVID-19) led to an ongoing pandemic with a surge of critically ill patients. Very little is known about the occurrence and characteristic of cardiac arrest in critically ill patients with COVID-19 treated at the intensive care unit (ICU). The aim was to investigate the incidence and outcome of intensive care unit cardiac arrest (ICU-CA) in critically ill patients with COVID-19. This was a retrospective analysis of prospectively recorded data of all consecutive adult patients with COVID-19 admitted (27 February 2020-14 January 2021) at the University Medical Centre Hamburg-Eppendorf (Germany). Of 183 critically ill patients with COVID-19, 18% ( = 33) had ICU-CA. The median age of the study population was 63 (55-73) years and 66% ( = 120) were male. Demographic characteristics and comorbidities did not differ significantly between patients with and without ICU-CA. Simplified Acute Physiological Score II (SAPS II) (ICU-CA: median 44 points vs. no ICU-CA: 39 points) and Sequential Organ Failure Assessment (SOFA) score (median 12 points vs. 7 points) on admission were significantly higher in patients with ICU-CA. Acute respiratory distress syndrome (ARDS) was present in 91% ( = 30) with and in 63% ( = 94) without ICU-CA ( = 0.002). Mechanical ventilation was more common in patients with ICU-CA (97% vs. 67%). The median stay in ICU before CA was 6 (1-17) days. A total of 33% ( = 11) of ICU-CAs occurred during the first 24 h of ICU stay. The initial rhythm was non-shockable (pulseless electrical activity (PEA)/asystole) in 91% ( = 30); 94% ( = 31) had sustained return of spontaneous circulation (ROSC). The median time to ROSC was 3 (1-5) minutes. Patients with ICU-CA had significantly higher ICU mortality (61% vs. 37%). Multivariable logistic regression showed that the presence of ARDS (odds ratio (OR) 4.268, 95% confidence interval (CI) 1.211-15.036; = 0.024) and high SAPS II (OR 1.031, 95% CI 0.997-1.065; = 0.077) were independently associated with the occurrence of ICU-CA. A total of 18% of critically ill patients with COVID-19 suffered from a cardiac arrest within the intensive care unit. The occurrence of ICU-CA was associated with presence of ARDS and severity of illness.
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http://dx.doi.org/10.3390/jcm10102195DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8160993PMC
May 2021

Necrotizing Soft Tissue Infections in Intensive Care.

J Intensive Care Med 2021 Apr 26:8850666211010127. Epub 2021 Apr 26.

Department of Intensive Care Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany.

Background: Necrotizing soft tissue infections (NSTIs) are typically characterized by extensive soft tissue destruction with systemic signs of toxicity, ranging from sepsis to septic shock. Our aim was to analyze the clinical characteristics, microbiological results, laboratory data, therapies, and outcome of patients with NSTIs admitted to an intensive care unit (ICU).

Methods: A monocentric observational study of patients admitted to the ICU of a university hospital between January 2009 and December 2017. The demographic characteristics, comorbidities, clinical features, microbiology and laboratory results, organ dysfunctions, therapies, and outcome were retrospectively analyzed.

Results: There were 59 patients and 70% males. The mean age (± SD) was 55 ± 18; type II (monomicrobial) NSTI was present in 36 patients (61%); the most common isolated pathogen was in 28 patients (48%). Septic shock was diagnosed in 41 patients (70%). The most common organ dysfunctions were circulatory and renal in 42 (71%) and 38 patients (64%). The mean value (± SD) of serum lactate at admission to the ICU was 4.22 ± 5.42 mmol/l, the median SOFA score and SAPS II were 7 (IQR 4 - 10) and 46 (IQR 30.5 - 53). ICU mortality rate was 25%. Both SOFA score and serum lactate demonstrated a good prognostic value regarding ICU outcome (OR 1.29, 95%CI 1.07-1.57, < 0.007 and OR 1.53, 95%CI 1.19-1.98, < 0.001). A cut-off value for serum lactate of 6.55 mmol/L positively predicted mortality with 67% sensitivity and 97% specificity.

Conclusion: NSTIs carry a high risk of septic shock and multiple organ dysfunction syndrome and thus are still associated with high mortality. In our study, the value of serum lactate at admission to the ICU correlated well with mortality. This easy-to-measure parameter could play a role in the decision-making process regarding prognosis and continuation of care.
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http://dx.doi.org/10.1177/08850666211010127DOI Listing
April 2021

MR-proAdrenomedullin as a predictor of renal replacement therapy in a cohort of critically ill patients with COVID-19.

Biomarkers 2021 Jul 5;26(5):417-424. Epub 2021 Apr 5.

Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.

Background: About 20% of ICU patients with COVID-19 require renal replacement therapy (RRT). Mid-regional pro-adrenomedullin (MR-proADM) might be used for risk assessment. This study investigates MR-proADM for RRT prediction in ICU patients with COVID-19.

Methods: We analysed data of consecutive patients with COVID-19, requiring ICU admission at a university hospital in Germany between March and September 2020. Clinical characteristics, details on AKI, and RRT were assessed. MR-proADM was measured on admission.

Results: 64 patients were included (49 (77%) males). Median age was 62.5y (54-73). 47 (73%) patients were ventilated and 50 (78%) needed vasopressors. 25 (39%) patients had severe ARDS, and 10 patients needed veno-venous extracorporeal membrane oxygenation. 29 (45%) patients required RRT; median time from admission to RRT start was 2 (1-9) days. MR-proADM on admission was higher in the RRT group (2.491 vs. 1.23 nmol/l;  = 0.002) and showed the highest correlation with renalSOFA. ROC curve analysis showed that MR-proADM predicts RRT with an AUC of 0.69 (95% CI: 0.543-0.828;  = 0.019). In multivariable logistic regression MR-proADM was an independent predictor (OR: 3.813, 95% CI 1.110-13.102, <0.05) for RRT requirement.

Conclusion: AKI requiring RRT is frequent in ICU patients with COVID-19. MR-proADM on admission was able to predict RRT requirement, which may be of interest for risk stratification and management.
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http://dx.doi.org/10.1080/1354750X.2021.1905067DOI Listing
July 2021

Severe liver dysfunction complicating course of COVID-19 in the critically ill: multifactorial cause or direct viral effect?

Ann Intensive Care 2021 Mar 15;11(1):44. Epub 2021 Mar 15.

Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.

Background: SARS-CoV-2 caused a pandemic and global threat for human health. Presence of liver injury was commonly reported in patients with coronavirus disease 2019 (COVID-19). However, reports on severe liver dysfunction (SLD) in critically ill with COVID-19 are lacking. We evaluated the occurrence, clinical characteristics and outcome of SLD in critically ill patients with COVID-19.

Methods: Clinical course and laboratory was analyzed from all patients with confirmed COVID-19 admitted to ICU of the university hospital. SLD was defined as: bilirubin ≥ 2 mg/dl or elevation of aminotransferase levels (> 20-fold ULN).

Results: 72 critically ill patients were identified, 22 (31%) patients developed SLD. Presenting characteristics including age, gender, comorbidities as well as clinical presentation regarding COVID-19 overlapped substantially in both groups. Patients with SLD had more severe respiratory failure (paO/FiO 82 (58-114) vs. 117 (83-155); p < 0.05). Thus, required more frequently mechanical ventilation (95% vs. 64%; p < 0.01), rescue therapies (ECMO) (27% vs. 12%; p = 0.106), vasopressor (95% vs. 72%; p < 0.05) and renal replacement therapy (86% vs. 30%; p < 0.001). Severity of illness was significantly higher (SAPS II: 48 (39-52) vs. 40 (32-45); p < 0.01). Patients with SLD and without presented viremic during ICU stay in 68% and 34%, respectively (p = 0.002). Occurrence of SLD was independently associated with presence of viremia [OR 6.359; 95% CI 1.336-30.253; p < 0.05] and severity of illness (SAPS II) [OR 1.078; 95% CI 1.004-1.157; p < 0.05]. Mortality was high in patients with SLD compared to other patients (68% vs. 16%, p < 0.001). After adjustment for confounders, SLD was independently associated with mortality [HR3.347; 95% CI 1.401-7.999; p < 0.01].

Conclusion: One-third of critically ill patients with COVID-19 suffer from SLD, which is associated with high mortality. Occurrence of viremia and severity of illness seem to contribute to occurrence of SLD and underline the multifactorial cause.
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http://dx.doi.org/10.1186/s13613-021-00835-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7957439PMC
March 2021

Mechanical ventilation and mortality among 223 critically ill patients with coronavirus disease 2019: A multicentric study in Germany.

Aust Crit Care 2021 Mar 27;34(2):167-175. Epub 2020 Oct 27.

Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.

Background: There are large uncertainties with regard to the outcome of patients with coronavirus disease 2019 (COVID-19) and mechanical ventilation (MV). High mortality (50-97%) was proposed by some groups, leading to considerable uncertainties with regard to outcomes of critically ill patients with COVID-19.

Objectives: The aim was to investigate the characteristics and outcomes of critically ill patients with COVID-19 requiring intensive care unit (ICU) admission and MV.

Methods: A multicentre retrospective observational cohort study at 15 hospitals in Hamburg, Germany, was performed. Critically ill adult patients with COVID-19 who completed their ICU stay between February and June 2020 were included. Patient demographics, severity of illness, and ICU course were retrospectively evaluated.

Results: A total of 223 critically ill patients with COVID-19 were included. The majority, 73% (n = 163), were men; the median age was 69 (interquartile range = 58-77.5) years, with 68% (n = 151) patients having at least one chronic medical condition. Their Sequential Organ Failure Assessment score was a median of 5 (3-9) points on admission. Overall, 167 (75%) patients needed MV. Noninvasive ventilation and high-flow nasal cannula were used in 31 (14%) and 26 (12%) patients, respectively. Subsequent MV, due to noninvasive ventilation/high-flow nasal cannula therapy failure, was necessary in 46 (81%) patients. Renal replacement therapy was initiated in 33% (n = 72) of patients, and owing to severe respiratory failure, extracorporeal membrane oxygenation was necessary in 9% (n = 20) of patients. Experimental antiviral therapy was used in 9% (n = 21) of patients. Complications during the ICU stay were as follows: septic shock (40%, n = 90), heart failure (8%, n = 17), and pulmonary embolism (6%, n = 14). The length of ICU stay was a median of 13 days (5-24), and the duration of MV was 15 days (8-25). The ICU mortality was 35% (n = 78) and 44% (n = 74) among mechanically ventilated patients.

Conclusion: In this multicentre observational study of 223 critically ill patients with COVID-19, the survival to ICU discharge was 65%, and it was 56% among patients requiring MV. Patients showed high rate of septic complications during their ICU stay.
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http://dx.doi.org/10.1016/j.aucc.2020.10.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7590821PMC
March 2021

Autopsy Findings and Venous Thromboembolism in Patients With COVID-19: A Prospective Cohort Study.

Ann Intern Med 2020 08 6;173(4):268-277. Epub 2020 May 6.

University Medical Center Hamburg-Eppendorf, Hamburg, Germany (D.W., J.S., M.L., S.S., C.E., A.H., F.H., H.M., I.K., A.S.S., C.B., G.D., A.N., D.F., S.P., S.S., C.B., M.M.A., M.A., K.P., S.K.).

Background: The new coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has caused more than 210 000 deaths worldwide. However, little is known about the causes of death and the virus's pathologic features.

Objective: To validate and compare clinical findings with data from medical autopsy, virtual autopsy, and virologic tests.

Design: Prospective cohort study.

Setting: Autopsies performed at a single academic medical center, as mandated by the German federal state of Hamburg for patients dying with a polymerase chain reaction-confirmed diagnosis of COVID-19.

Patients: The first 12 consecutive COVID-19-positive deaths.

Measurements: Complete autopsy, including postmortem computed tomography and histopathologic and virologic analysis, was performed. Clinical data and medical course were evaluated.

Results: Median patient age was 73 years (range, 52 to 87 years), 75% of patients were male, and death occurred in the hospital ( = 10) or outpatient sector ( = 2). Coronary heart disease and asthma or chronic obstructive pulmonary disease were the most common comorbid conditions (50% and 25%, respectively). Autopsy revealed deep venous thrombosis in 7 of 12 patients (58%) in whom venous thromboembolism was not suspected before death; pulmonary embolism was the direct cause of death in 4 patients. Postmortem computed tomography revealed reticular infiltration of the lungs with severe bilateral, dense consolidation, whereas histomorphologically diffuse alveolar damage was seen in 8 patients. In all patients, SARS-CoV-2 RNA was detected in the lung at high concentrations; viremia in 6 of 10 and 5 of 12 patients demonstrated high viral RNA titers in the liver, kidney, or heart.

Limitation: Limited sample size.

Conclusion: The high incidence of thromboembolic events suggests an important role of COVID-19-induced coagulopathy. Further studies are needed to investigate the molecular mechanism and overall clinical incidence of COVID-19-related death, as well as possible therapeutic interventions to reduce it.

Primary Funding Source: University Medical Center Hamburg-Eppendorf.
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http://dx.doi.org/10.7326/M20-2003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7240772PMC
August 2020

Clinical Nutrition in Critical Care Medicine - Guideline of the German Society for Nutritional Medicine (DGEM).

Clin Nutr ESPEN 2019 10 9;33:220-275. Epub 2019 Jul 9.

Department for Nutritional Medicine, University of Hohenheim, Fruwirthstr. 12, 70599, Stuttgart, Germany. Electronic address:

Purpose: Enteral and parenteral nutrition of adult critically ill patients varies in terms of the route of nutrient delivery, the amount and composition of macro- and micronutrients, and the choice of specific, immune-modulating substrates. Variations of clinical nutrition may affect clinical outcomes. The present guideline provides clinicians with updated consensus-based recommendations for clinical nutrition in adult critically ill patients who suffer from at least one acute organ dysfunction requiring specific drug therapy and/or a mechanical support device (e.g., mechanical ventilation) to maintain organ function.

Methods: The former guidelines of the German Society for Nutritional Medicine (DGEM) were updated according to the current instructions of the Association of the Scientific Medical Societies in Germany (AWMF) valid for a S2k-guideline. According to the S2k-guideline classification, no systematic review of the available evidence was required to make recommendations, which, therefore, do not state evidence- or recommendation grades. Nevertheless, we considered and commented the evidence from randomized-controlled trials, meta-analyses and observational studies with adequate sample size and high methodological quality (until May 2018) as well as from currently valid guidelines of other societies. The liability of each recommendation was described linguistically. Each recommendation was finally validated and consented through a Delphi process.

Results: In the introduction the guideline describes a) the pathophysiological consequences of critical illness possibly affecting metabolism and nutrition of critically ill patients, b) potential definitions for different disease phases during the course of illness, and c) methodological shortcomings of clinical trials on nutrition. Then, we make 69 consented recommendations for essential, practice-relevant elements of clinical nutrition in critically ill patients. Among others, recommendations include the assessment of nutrition status, the indication for clinical nutrition, the timing and route of nutrient delivery, and the amount and composition of substrates (macro- and micronutrients); furthermore, we discuss distinctive aspects of nutrition therapy in obese critically ill patients and those treated with extracorporeal support devices.

Conclusion: The current guideline provides clinicians with up-to-date recommendations for enteral and parenteral nutrition of adult critically ill patients who suffer from at least one acute organ dysfunction requiring specific drug therapy and/or a mechanical support device (e.g., mechanical ventilation) to maintain organ function. The period of validity of the guideline is approximately fixed at five years (2018-2023).
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http://dx.doi.org/10.1016/j.clnesp.2019.05.002DOI Listing
October 2019

[DGEM Guideline "Clinical Nutrition in Critical Care Medicine" - short version].

Anasthesiol Intensivmed Notfallmed Schmerzther 2019 Jan 8;54(1):63-73. Epub 2019 Jan 8.

Purpose: Variations of clinical nutrition may affect outcome of critically ill patients. Here we present the short version of the updated consenus-based guideline (S2k classification) "Clinical nutrition in critical care medicine" of the German Society for Nutritional Medicine (DGEM) in cooperation with 7 other national societies. The target population of the guideline was defined as critically ill adult patients who suffer from at least one acute organ dysfunction requiring specific drug therapy and/or a mechanical support device (e.g. mechanical ventilation) to maintain organ function.

Methods: The former guidelines of the German Society for Nutritional Medicine (DGEM) were updated according to the current instructions of the Association of the Scientific Medical Societies in Germany (AWMF) valid for a S2k-guideline. We considered and commented the evidence from randomized-controlled trials, meta-analyses and observational studies with adequate sample size and high methodological quality (until May 2018) as well as from currently valid guidelines of international societies. The liability of each recommendation was indicated using linguistic terms. Each recommendation was finally validated and consented by a Delphi process.

Results: The short version presents a summary of all 69 consented recommendations for essential, practice-relevant elements of clinical nutrition in the target population. A specific focus is the adjustment of nutrition according to the phases of critical illness, and to the individual tolerance to exogenous substrates. Among others, recommendations include the assessment of nutritional status, the indication for clinical nutrition, the timing, route, magnitude and composition of nutrition (macro- and micronutrients) as well as distinctive aspects of nutrition therapy in obese critically ill patients and those with extracorporeal support devices.

Conclusion: The current short version of the guideline provides a concise summary of the updated recommendations for enteral and parenteral nutrition of adult critically ill patients who suffer from at least one acute organ dysfunction requiring pharmacological and/or mechanical support. The validity of the guideline is approximately fixed at five years (2018 - 2023).
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http://dx.doi.org/10.1055/a-0805-4118DOI Listing
January 2019

[Lactic acidosis - update 2018].

Dtsch Med Wochenschr 2018 08 30;143(15):1082-1085. Epub 2018 Jul 30.

Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf.

Severe hyperlactaemia in intensive care patients is most often due to underlying sepsis or septic, cardiogenic or haemorrhagic shock. Hyperlactaemia is an independent predictor of death in various groups of critically ill patients. With serum lactate values > 10 mmol/l 80 % of the patients die in intensive care, and if the severe lactic acidosis persists for 48 hours, all patients die. Increased lactate levels require immediate diagnostic work-up and classification. The new sepsis definition requires a serum lactate > 2 mmol/l for septic shock with adequate volume substitution and vasopressor administration in order to achieve a mean arterial pressure in persistent hypotension ≥ 65 mmHg. The 1-hour bundle of the Surviving Sepsis Campaign published in 2018 recommends as a first measure the determination of the lactate serum concentrations, and increased values should be closely monitored. In addition, blood culture sampling, broad-spectrum antibiotics, fluid resuscitation and vasopressor administration are recommended within the first hour. Large amounts of crystalloids should be given for increased lactate levels (≥ 4 mmol/l) and refractory hypotension, the administration of fluids can be adjusted according to lactate clearance. Lactate metabolism is prolonged in patients with liver function impairment. Lactate levels on admission to intensive care are significantly associated with the number of failing organs and mortality in patients with cirrhosis. 12-hour lactate clearance has a strong predictive prognosis for survival in patients with baseline lactate levels above 5 mmol/l, the latter remains an independent predictor for the severity of the underlying disease even after correction. The greater the decrease in lactate during the initial therapy, the better the outcome.
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http://dx.doi.org/10.1055/a-0585-7986DOI Listing
August 2018

Intravenous fish oil in critically ill and surgical patients - Historical remarks and critical appraisal.

Clin Nutr 2018 06 13;37(3):1075-1081. Epub 2017 Jul 13.

Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Germany. Electronic address:

The purpose of this review is to explain the historical and clinical background for intravenous fish oil administration, to evaluate its results by using a product specific metaanalysis, and to stimulate further research in the immune-modulatory potential of fish oil. Concerning the immune-modulatory effects of fatty acids, a study revealed that ω-3 as well as ω-6 fatty acids would prolong transplant survival, and only a mixture with an ω-6:ω-3 ratio of 2.1:1 would give immune-neutral results. In 1998, the label of a newly registered fish oil emulsion also acknowledged this immune-neutral ratio in conjunction with ω-6 lipids. Also, two fish oil-supplemented fat emulsions, registered in 2004, used a similar ω-6:ω-3 ratio. Such an immune-neutral ω-6:ω-3 ratio denoted progress for most patients compared to pure ω-6 lipid emulsions. However, this immune-neutrality might on the other hand be responsible for the limited positive clinical results gained so far in critically ill and surgical patients where in most cases significance could only be shown for the pooled effect of numerous trials. Our product specific metaanalysis also did not reveal any differences, neither in infections rates nor in ICU or hospital length of stay. To evaluate the immune-modulatory effect of fish oil administered alone, new dose finding studies, reporting relevant clinical outcome parameters, are required. Precise mechanistic or physiological biomarkers for the indication of such a therapy should also be developed and validated.
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http://dx.doi.org/10.1016/j.clnu.2017.07.006DOI Listing
June 2018

Advance Directives and Powers of Attorney in Intensive Care Patients.

Dtsch Arztebl Int 2017 Jun;114(21):363-370

Department of Intensive Care Medicine, Center for Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf (UKE); Department of Anesthesiology, Center for Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf (UKE); Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf (UKE).

Background: Advance directives and powers of attorney are increasingly common, yet data on their use in clinical situations remain sparse.

Methods: In this single center cross-sectional study, we collected data by questionnaire from 1004 intensive care patients in a university hospital. The frequencies of advance directives and powers of attorney were determined, and the factors affecting them were studied with multivariate logistic regression analysis.

Results: Usable data were obtained from 998 patients. 51.3% stated that they had prepared a document of at least one of these two kinds. Among them, 39.6% stated that they had given the relevant document(s) to the hospital, yet such documents were present in the patient's hospital record for only 23%. 508 patients stated their reasons for preparing an advance directive or a power of attorney: the most common reason (48%) was the fear of being at other people's mercy, of the lack of self-determination, or of medical overtreatment. The most important factors associated with a patient's statement that he/she had prepared such a document were advanced age (advance directive: 1.022 [1.009; 1.036], p = 0.001; power of attorney: 1.027 [1.014; 1.040], p<0.001) and elective admission to the hospital (advance directive: 1.622 [1.138; 2.311], p<0.007; power of attorney: 1.459 [1.049; 2.030], p = 0.025). 39.8% of the advance directives and 44.1% of the powers of attorney that were present in the hospital records were poorly interpretable because of the incomplete filling-out of preprinted forms. Half of the patients who did not have such a document had already thought of preparing one, but had not yet done so.

Conclusion: For patients hospitalized in intensive care units, there should be early discussion about the presence or absence of documents of these kinds and early evaluation of the patient's concrete wishes in critical situations. Future studies are needed to determine how best to assure that these documents will be correctly prepared and then given over to hospital staff so that they can take their place in the patient's record.
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http://dx.doi.org/10.3238/arztebl.2017.0363DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5478788PMC
June 2017

High-Flow Nasal Cannula Versus Bag-Valve-Mask for Preoxygenation Before Intubation in Subjects With Hypoxemic Respiratory Failure.

Respir Care 2016 Sep 7;61(9):1160-7. Epub 2016 Jun 7.

Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.

Background: Critically ill patients with respiratory failure undergoing intubation have an increased risk of hypoxemia-related complications. Delivering oxygen via a high-flow nasal cannula (HFNC) has theoretical advantages and is increasingly used. This study was conducted to compare HFNC with bag-valve-mask (BVM) for preoxygenation and to assess oxygenation during intubation in subjects with hypoxemic respiratory failure.

Methods: This study was a randomized controlled trial including 40 critically ill subjects with hypoxemic respiratory failure who received either HFNC or BVM for preoxygenation before intubation in the ICU. The primary outcome was the mean lowest SpO2 during intubation.

Results: The mean lowest SpO2 during intubation was 89 ± 18% in the HFNC group and 86 ± 11% in the BVM group (P = .56). In subjects receiving HFNC, a significant increase in SpO2 after preoxygenation was only seen in those previously receiving low-flow oxygen (P = .007), whereas there was no significant difference in SpO2 in subjects previously receiving noninvasive ventilation or HFNC (P = .73). During the 1 min of apnea after the induction of anesthesia, SpO2 dropped significantly in the BVM group (P = .001), whereas there was no significant decrease in the HFNC group (P = .17). There were no significant differences between the 2 groups at any of the predefined time points before or after intubation concerning SpO2 , PaO2 /FIO2 , and PaCO2 .

Conclusions: Preoxygenation using HFNC before intubation was feasible and safe compared with BVM in critically ill subjects with acute, mild to moderate hypoxemic respiratory failure. There was no significant difference in the mean lowest SpO2 during intubation between the HFNC and the BVM group. There was also no significant difference in SpO2 between the 2 groups at any of the predefined time points. However, on continuous monitoring, there was a significant decrease in SpO2 during the apnea phase before intubation in the BVM group, which was not seen in the HFNC group. (ClinicalTrials.gov registration NCT01994928.).
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http://dx.doi.org/10.4187/respcare.04413DOI Listing
September 2016

Clinical characteristics and outcome of very elderly patients ≥90 years in intensive care: a retrospective observational study.

Ann Intensive Care 2015 Dec 21;5(1):53. Epub 2015 Dec 21.

Department of Intensive Care Medicine, University medical center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.

Background: Since the overall prognosis of very elderly patients is generally limited, admissions to intensive care in these patients are often restricted. Therefore, only very few information is available on the prognosis of nonagenarians after intensive care treatment. The aim of this study was to analyze the clinical characteristics and outcomes of very elderly patients (≥90 years) admitted to an intensive care unit (ICU).

Methods: Monocentric, retrospective observational study of all patients aged ≥90 years admitted to the Department of Intensive Care Medicine with a total capacity of 132 ICU beds at the University Medical Center Hamburg in Germany between January 2008 and June 2013. A multivariate Cox regression analysis was used to identify risk factors for 28-day outcome.

Results: A total of 372 patients ≥90 years of age were admitted to one of the departments ICUs. The majority of patients (66.7 %) were admitted as an emergency admission, of which half underwent unscheduled surgery. 39.8 % of patients required support by mechanical ventilation and vasoactive drugs, and 1.9 % of patients received renal replacement. ICU and hospital mortality rates were 18.3 and 30.9 %, respectively. Overall survival at 1 year after hospital discharge was 34.9 %. Multivariate Cox regression analysis revealed creatinine, bilirubin, age, and necessity of catecholamines as independent risk factors and scheduled surgery as protective factor for 28-day outcome.

Conclusion: Nearly 70 % of patients aged ≥90 years were discharged alive from hospital following treatment at the ICU, and more than half of them were still alive 1 year after their discharge. The results suggest that 1-year survival prognosis of very old ICU patients is not as poor as often perceived and that age per se should not be an exclusion criterion for ICU admission.

Trial Registration: WF-0561/13.
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http://dx.doi.org/10.1186/s13613-015-0097-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4686461PMC
December 2015

A nutrition strategy for obese ICU patients with special consideration for the reference of protein.

Clin Nutr ESPEN 2015 Oct 28;10(5):e160-e166. Epub 2015 Aug 28.

Department of Intensive Care Medicine, University Medical Center of Hamburg Eppendorf, Germany. Electronic address:

Hypocaloric, high protein feeding regimens have been proposed for feeding obese critically ill patients. However, the exact amount of energy and protein that should be provided to the obese patients with these regimens is still under discussion. Furthermore, the body compartment to be used as a reference for appropriate protein dosing has not yet been determined. While both actual and ideal body weight have been proposed, neither is an accurate reflection of total body protein content in obese individuals. Alternatively, dosing protein based on lean body mass (LBM), which is highly correlated with total body protein, might be the most appropriate method of calculating protein requirements as defined by actual body composition. LBM can be measured or estimated by various methods. We herein discuss a rationale to determine both the energy and protein needs to use in hypocaloric feeding regimens for obese patients based on the use of Standard Body Weight (SBW) and LBM, using previously published body composition data from 1420 healthy volunteers. When applied to the obese population, and compared to current practices, this method results in highly significant differences for both total and gender-specific protein dosing.
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http://dx.doi.org/10.1016/j.clnesp.2015.07.001DOI Listing
October 2015

A case of severe Ebola virus infection complicated by gram-negative septicemia.

N Engl J Med 2014 Dec 22;371(25):2394-401. Epub 2014 Oct 22.

From the Division of Tropical Medicine, First Department of Medicine (B.K., A.W.L., M.M.A., S.S.), Department of Intensive Care Medicine (D.W., G.H., S.K.), Institute for Clinical Chemistry and Laboratory Medicine (T.R.), and Infectious Disease Unit for Outpatient Care (S.S.), University Medical Center Hamburg-Eppendorf, the German Center for Infection Research, Hamburg-Borstel-Lübeck (B.K., J.S.-C., S.G., A.W.L., M.M.A., S.S.), the Research Group for Infectious Disease Epidemiology, Bernhard Nocht Institute for Tropical Medicine (B.K.), and the Bernhard Nocht Institute for Tropical Medicine, World Health Organization Collaborating Center for Arbovirus and Hemorrhagic Fever Reference and Research (P.E., J.S.-C., S.G.) - all in Hamburg, Germany; Arboviruses and Hemorrhagic Fever Viruses Unit, Pasteur Institute, and Public Health and Development Institute, Cheikh Anta Diop University - both in Dakar, Senegal (A.S.); Bordeaux Public Health Institute, INSERM Unité 897, Bordeaux University, Bordeaux, France (A.S); the Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm (T.R.); and the Infectious Diseases Unit, Massachusetts General Hospital, Boston (M.M.A.).

Ebola virus disease (EVD) developed in a patient who contracted the disease in Sierra Leone and was airlifted to an isolation facility in Hamburg, Germany, for treatment. During the course of the illness, he had numerous complications, including septicemia, respiratory failure, and encephalopathy. Intensive supportive treatment consisting of high-volume fluid resuscitation (approximately 10 liters per day in the first 72 hours), broad-spectrum antibiotic therapy, and ventilatory support resulted in full recovery without the use of experimental therapies. Discharge was delayed owing to the detection of viral RNA in urine (day 30) and sweat (at the last assessment on day 40) by means of polymerase-chain-reaction (PCR) assay, but the last positive culture was identified in plasma on day 14 and in urine on day 26. This case shows the challenges in the management of EVD and suggests that even severe EVD can be treated effectively with routine intensive care.
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http://dx.doi.org/10.1056/NEJMoa1411677DOI Listing
December 2014

Use of polyclonal immunoglobulins as adjunctive therapy for sepsis or septic shock.

Crit Care Med 2007 Dec;35(12):2677-85

Department of Intensive Care, University Medical Centre, Hamburg-Eppendorf, Germany.

Objective: There is ongoing debate about the efficacy of polyvalent immunoglobulins as adjunctive therapy for sepsis or septic shock. Two meta-analyses by the Cochrane collaboration calculated a significant reduction in mortality. However, data of the largest study were missing in one, and a subset of four high-quality studies failed to show an effect in the other. To broaden the database, we performed a meta-analysis of all randomized controlled studies published so far.

Data Source: MEDLINE, EMBASE, Cochrane Library of randomized trials, and personal files.

Study Selection: Meta-analysis of all published randomized controlled studies published on polyvalent immunoglobulins (Ig) for treatment of sepsis or septic shock in adults, children, or neonates.

Data Extraction: Twenty-seven trials with a total of 2,202 patients fulfilled the inclusion criteria.

Data Synthesis: As the immunologic state of neonates is different than that of adults or older children, data were evaluated separately for each group. Fifteen trials on 1,492 adults could be included. The pooled effect on mortality was a relative risk of death (RR) of 0.79 (95% confidence interval [CI] 0.69-0.90, p
Conclusions: Polyvalent immunoglobulins exert a significant effect on mortality in sepsis and septic shock, with a trend in favor of IgGAM.
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December 2007

Prediction of short-term and long-term outcomes after cardiac arrest: a prospective multivariate approach combining biochemical, clinical, electrophysiological, and neuropsychological investigations.

Crit Care Med 2007 May;35(5):1230-7

Department of Biological Psychology and Neuropsychology, University of Hamburg, Germany.

Objective: To determine the prognostic accuracy of biochemical, clinical, electrophysiological, and neuropsychological investigations in predicting outcomes after cardiac arrest.

Design: Prospective study.

Setting: Intensive care unit of the Hamburg-Eppendorf University Medical Center, Hamburg, Germany.

Patients: A total of 80 patients (mean age, 63.79 +/- 15.85 yrs) after cardiopulmonary resuscitation.

Interventions: Serial blood samples (days 2-4), clinical examinations (days 2 and 4), sensory-evoked potentials (day 4), and neuropsychological assessments (
Measurements And Main Results: We conducted a prospective study into the combined predictive efficacy of serum concentrations of neuron-specific enolase and protein S-100B, standardized clinical examinations, and short- and long-latency sensory-evoked potentials. For the prognostic validation, both the dichotomized 5-point Glasgow-Pittsburgh Cerebral Performance Categories (1-3, favorable outcome; 4-5, unfavorable outcome) and a comprehensive neuropsychological test battery were applied. A multivariate logistic-regression analysis resulted in a model in which 85% of the variance in the dichotomized Glasgow-Pittsburgh Cerebral Performance Categories was explained by neuron-specific enolase at day 4, clinical examination score at day 4, and age. This predictor index had a sensitivity of 92% and a specificity of 93%. In addition, 26 patients (out of 33) underwent neuropsychological testing at 6 months. Significant correlations were found with selected cognitive variables and S-100B at day 3, long-latency sensory-evoked potential at day 4, and neuropsychological bedside screening.

Conclusions: A multivariate assessment approach should be used to establish an early high-certainty prognosis after cardiac arrest. However, further prospective clinical studies are necessary to confirm this derived predictor index. In addition, an early recording of S-100B, long-latency sensory-evoked potential, and neuropsychological bedside screening reflect a cognitive long-term outcome.
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http://dx.doi.org/10.1097/01.CCM.0000261892.10559.85DOI Listing
May 2007
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