Intensivmedizin + Notfallmedizin : Organ der Deutschen und der Osterreichischen Gesellschaft fur internistische Intensivmedizin, der Sektion Neurologie der DGIM und der Sektion Intensivmedizin im Berufsverband Deutscher Internisten e.V最新文献

Patients with imported highly contagious diseases like viral hemorrhagic fever (VHF), pneumonic plague or anthrax require special preventive measures and strict isolation. In addition, new emerging infections like severe acute respiratory syndrome (SARS) and epidemic influenza also have to be taken into account. At present five high security infectious disease units for patient care are available in Germany. Due to the relatively nonspecific symptoms, a patient with one of these infections may also be admitted to any other hospital. Therefore each hospital should develop a concept for the management and control of these lifethreatening highly contagious diseases. The present article describes the current emergency plan developed for the management of patients with highly contagious diseases at Hannover Medical School.

A hospital emergency plan commonly consists of three main chapters dealing with the general aspects of emergency operation and the special aspects of external and internal emergencies. The extent of these chapters is restricted to general understanding and is completed by special instructions (emergency action plan, staff lists, material lists, situation plans) for each department. Due to its security significance, the emergency plan is handled confidential. External emergencies include mass casualty incidents, incidents with a large number of intoxicated patients, the care of patients with dangerous infectious diseases and NBC emergencies. Internal emergencies include fire and other environmental threats, the breakdown of the electrical power and water supply, the breakdown of the telephone system and other situations like bomb threat and taking of hostages. Any emergency call is sent to a special emergency phone, and a defined, experienced physician decides to activate the emergency plan. With the change from routine to emergency service, a chain of command is installed. The hospital staff deals with administrational and organizational aspects, whereas the medical staff is in charge of immediate patients' care. For each external emergency, the deployment of personnel and material and the basic organizational aspects are ordered. Comparable preparations are given for internal emergencies. To achieve realistic emergency planning, repeated evaluations and practical exercises are necessary. Furthermore, a basic independence of the hospital with respect to stocks, preparation and sterilization of instruments and catering is essential to ensure its function even under adverse conditions.

Infection with Varicella zoster virus (VZV) usually occurs in children up to 15 years with mild symptoms. We present a case of a 22-year old man with a fatal varicella zoster infection. He developed fulminant hepatitis with acute liver failure and an acute respiratory distress syndrom (ARDS). In this article the general aspects of VZV infection are discussed. Treatment options and previous publications are reviewed.

The early diagnosis of sepsis is mandatory for the further reduction of mortality due to sepsis. Current findings exist that accentuate the role of the time factor, comparable with acute myocardial infarction or with ischemic stroke. On the other hand, there are no generally accepted diagnostics for sepsis, realizing the demands of early diagnosis and based on the physician's experience.The diagnostics start with the recognition of the inflammatory reaction caused by infection (at least 2 of 4 criteria of inflammatory reaction have to be fulfilled). This definition has high sensitivity, but remarkably lower specificity and it leads either to too frequent admissions or only to hospitalization in case of a complicating organ failure. Making a careful history and knowledge about sepsis are essential for the out-patient department physicians. In addition to the varying pictures of sepsis, the clinicians have laboratory findings available, most of all procalcitonin. Patients have to be considered as septic with a serum PCT level higher than 1 ng/ml particularly when clinical signs do not exclude sepsis and in cases of positive blood cultures. Initially PCT is a product of macrophages if the defense reaction starts, but it becomes an infection marker, when the serum PCT level declines less than the half life falls.

Nosocomial pneumonia is among the most frequent infections in the intensive care unit with high morbidity and mortality. The decisive factor for treatment failure is inadequate previous antibiotic treatment. Broad spectrum and sufficiently high dosed initial treatment is crucial.To prevent further resistances, the antibiotic treatment must be evaluated early. Depending on the treatment success, treatment has to be changed or terminated. Deescalation is possible and sensible after three days. A treatment period of seven days should not routinely be exceeded. The treatment recommendations should be adapted to local resistances and the local statistics of frequent pathogens. A further factor for treatment decision-making is the risk analysis of the patient (previous treatment, stays in hospitals or nursing homes, concomitant diseases).

The number of HIV-infected patients in Germany has increased steadily over time. This is due to the positive development of decreasing death rates and a nearly stable rate of new infections. This development is based on the improved prognosis for HIV/AIDS patients due to the introduction of highly active antiretroviral therapy (HAART) in 1996. Considering this, a new look at the HIV patient as a potential ICU candidate is necessary.    The most common referral for ICU therapy is respiratory failure, followed by neurological disorders. In rare cases, HAART-induced side-effects require therapy in the ICU.    Very few clinical trials directly compare the outcome of HIV-positive and HIV-negative patients, and most of these data were collected in the pre-HAART era. The ICU outcome does not correlate with HIV-genuine parameters, such as the CD4 cell counts. Thus, a HIV patient can benefit from ICU treatment.    Regarding HAART management, open questions still exist especially considering the mechanically ventilated patient. Actually only AZT (Retrovir®) is available as an i.v. formulation. Other antiretroviral medication can only be administered after grinding the tablets. The consequenses of the altered galenic composition with regard to efficacy and development of resistance has not been sufficiently studied. This also applies to risks and benefits of interrupted therapy versus a possibly inappropriate application of HAART.    In this survey we also describe possible interactions between HAART and sedative/antiepileptic/tuberculostatic etc. medication.    Finally special aspects of HIV exposure in the health care setting are discussed, including essential immediate measures after an injury. Current recommendations for post-exposure prophylaxis are given.