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

Acute liver failure represents a serious life-threatening event comparable to acute heart failure with cardiogenic shock or acute renal failure. Underlying acute liver diseases leading to hepatic failure differ between different geographic regions and in their incidence rates. In Europe etiological agents like viruses, drugs and toxins predominate over other much rarer causes. The different noxious agents lead to hepatocellular necrosis and/or apoptosis with loss of liver cell specific functions subsequent to a fall of functioning hepatocytes below a critical number. The syndrome is clinically characterized by the rapid onset of hepatic encephalopathy within 7 days after a first manifestation of liver disease (fulminant liver disease). Liver failure in patients with preexisting chronic liver disease is largely defined by the time which elapses between the occurrence of jaundice and encephalopathy (hyperacute, acute, subacute liver failure). The acute loss of liver specific functions is accompanied by a number of severe life-threatening complications like cerebral edema, circulatory failure, infections, renal failure and defective coagulation. Management of patients with fulminant liver disease requires a profound knowledge of hepatology and intensive care medicine. A close cooperation with a liver transplant unit is an absolute prerequisite for successful therapy. Permanent or temporary auxiliary liver replacement by a healthy human liver allows for a survival of 60 to 70% of patients selected for such a transplant procedure. Progress has been made in the temporary substitution of specific liver cell functions bridging the time period between liver failure and resumption of hepatocellular functions or availability of a donor liver. Different artificial livers have been designed and introduced into clinical trials. However, further evaluation is urgently needed.

Despite ongoing discussions, ECMO (extracorporeal membrane oxygenation) has become an important part of treatment options in acute lung injury and ARDS (acute respiratory distress syndrome) even in adults. On the other hand, none of the two RCT (randomized controlled trial) studies resulted in reduced letality of the artificial lung therapy when compared to convention treatment. Both authors concluded, that ECMO is not recommended in ARDS. Meanwhile experience with ECMO in adults is extensive in various institutions worldwide, exceeding 1000 patients by the end of 2001. Growing experience and improved technical equipment reduce the rate of technical complications substantially. However, for different reasons ECMO incidence in adults is progressively decreasing in recent years.    Inclusion and exclusion criteria vary among different ECMO centers. Potential reversibility of lung injury and persisting life-threatening gas exchange disorder under maximal conventional therapy are commonly seen as requirements for ECMO therapy. ECMO criteria are Murray lung injury score >3.5 (chest x-ray, PaO₂/FiO₂-index, static compliance C_stat, PEEP), Morel-classification >3 (chest x-ray, AaDO₂/FiO₂-index, C_stat, PEEP), AaDO2 >600mmHg, intrapulmonal shunt Q_S/Q_T >30%, and increase in extravascular lung water >15 ml/kg bodyweight.    Commonly accepted absolute contraindications are (1) severely consuming disorders with poor prognosis, (2) CNS damage with poor prognosis, (3) advanced chronic lung disorders, and (4) progressive multiple organ failure. Relative contraindications are immunosuppresion, active bleeding, age over 60 years, and days on mechanical ventilation.    In our experience, early contact to an ECMO reference center can optimise early identification of patients which benefit from ECMO, as well as treatment and transportation modalities, and improves outcome. Due to high technical and personal requirements and decreasing incidence in the adult sector, ECMO should be limited to a small number of reference centers with substantial experience in extracorporeal circulation.

The last two decades have seen a marked change in the role of plasmapheresis in the intensive care unit (ICU). Initially regarded as highly effective in treating virtually any immunological disease, insights in pathophysiology and results from controlled trials have left only a few indications validated. To date, plasmapheresis is indicated for acute treatment of severe immunological disorders either unresponsive to immunosuppression or requiring large volumes of human plasma for therapy. In the future, more specific and less cumbersome methods of immunosuppression and immunomodulation might further limit indications of plasmapheresis. In this review, current indications and side-effects of plasmapheresis in the ICU setting are summarized.