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Venous reperfusion as well as double-lumen cannulae for extracorporeal gas exchange (ECMO) are usually inserted via the right internal jugular vein. The supraclavicular approach to the right or left subclavian vein could serve as a possible alternative. The aim of this analysis was to compare feasibility, complications, and performance of supraclavicular and jugular cannulation, respectively.We retrospectively analysed charts and registry data of patients undergoing veno-venous ECMO. Twenty-four patients underwent jugular cannulation and 11 patients underwent supraclavicular cannulation. Ten patients underwent femoro-jugular and 5 patients underwent femoro-supraclavicular ECMO. Double lumen cannulae were inserted via the jugular approach in 14 patients and via the supraclavicular approach in 6 patients.No cannulation associated complications but for a single minor bleeding from the insertion site of a supraclavicular double lumen cannula were recorded. Performance of the extracorporeal circuit was comparable between jugular and supraclavicular groups but for a more pronounced oxygenation effect in the supraclavicular double-lumen group due to higher blood flows via larger (24F) cannulae.The supraclavicular approach seems safe and equivalent to jugular cannulation and could serve as a valid alternative. Copyright © 2017 by the American Society for Artificial Internal Organs

Valentin A.,Vienna University Hospital | Ferdinande P.,University Hospital Gasthuisberg
Intensive Care Medicine | Year: 2011

Objective: To provide guidance and recommendations for the planning or renovation of intensive care units (ICUs) with respect to the specific characteristics relevant to organizational and structural aspects of intensive care medicine. Methodology: The Working Group on Quality Improvement (WGQI) of the European Society of Intensive Care Medicine (ESICM) identified the basic requirements for ICUs by a comprehensive literature search and an iterative process with several rounds of consensus finding with the participation of 47 intensive care physicians from 23 countries. The starting point of this process was an ESICM recommendation published in 1997 with the need for an updated version. Results: The document consists of operational guidelines and design recommendations for ICUs. In the first part it covers the definition and objectives of an ICU, functional criteria, activity criteria, and the management of equipment. The second part deals with recommendations with respect to the planning process, floorplan and connections, accommodation, fire safety, central services, and the necessary communication systems. Conclusion: This document provides a detailed framework for the planning or renovation of ICUs based on a multinational consensus within the ESICM. © jointly held by Springer and ESICM 2011.

Adams D.H.,Mount Sinai School of Medicine | Rosenhek R.,Vienna University Hospital | Falk V.,University of Zürich
European Heart Journal | Year: 2010

Degenerative mitral valve disease often leads to leaflet prolapse due to chordal elongation or rupture, and resulting in mitral valve regurgitation. Guideline referral for surgical intervention centres primarily on symptoms and ventricular dysfunction. The recommended treatment for degenerative mitral valve disease is mitral valve reconstruction, as opposed to valve replacement with a bioprosthetic or mechanical valve, because valve repair is associated with improved event free survival. Recent studies have documented a significant number of patients are not referred in a timely fashion according to established guidelines, and when they are subjected to surgery, an alarming number of patients continue to undergo mitral valve replacement. The debate around appropriate timing of intervention for asymptomatic severe mitral valve regurgitation has put additional emphasis on targeted surgeon referral and the need to ensure a very high rate of mitral valve repair, particularly in the non-elderly population. Current clinical practice remains suboptimal for many patients, and this review explores the need for a 'best practice revolution' in the field of degenerative mitral valve regurgitation. © The Author 2010.

Ball E.M.,The University of Shimane | Ball E.M.,Vienna University Hospital
Rheumatology (Oxford, England) | Year: 2014

OBJECTIVES: The aims of this study were to investigate the extent of MRI-determined joint disease (erosion and synovitis) in SLE and to link this to autoantibody profiles known to be relevant to SLE, including ACPA, RF and anti-RA33 antibodies.METHODS: Contrast-enhanced MRI of the hand and wrist was performed in 34 symptomatic SLE patients and in 15 RA patients with similar disease duration. Images were scored by two observers using the OMERACT rheumatoid arthritis MRI scoring (RAMRIS) system. Findings were correlated with clinical examination and autoantibody status.RESULTS: Erosions were present at the wrist in 93% of SLE patients and at the MCP joints in 61% of SLE patients. Despite the high prevalence of MRI-determined erosion, only 8.8% of SLE patients were ACPA positive, although these patients had a higher burden of erosive disease. There was no positive correlation with anti-RA33 titres and erosion scores in the SLE patients, but there was a negative correlation with anti-RA33 titres and total bone oedema scores in the SLE patients. Ninety-three per cent of SLE patients had at least grade 1 synovitis at one or more MCP joints, and wrist joint synovitis was present in all the SLE patients.CONCLUSION: An MRI-determined joint erosive phenotype is common in SLE, even in ACPA-negative cases. The conventional radiographic observation that anti-RA33 is not positively associated with erosion in patients with RA was also found to be the case in SLE patients. © The Author 2014. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For Permissions, please email:

Hafner C.,Vienna University Hospital
Shock | Year: 2016

ABSTRACT: Supplemental oxygen (O2) is used as adjunct therapy in anesthesia, emergency and intensive care medicine. We hypothesized that excessive O2 levels (hyperoxia) can directly injure human adult cardiac myocytes (HACMs). HACMs obtained from the explanted hearts of transplantation patients were exposed to constant hyperoxia (95% O2), intermittent hyperoxia (alternating 10?min exposures to 5% and 95% O2), constant normoxia (21% O2), or constant mild hypoxia (5% O2) using a bioreactor. Changes in cell morphology, viability as assessed by lactate dehydrogenase (LDH) release and trypan blue (TB) staining, and secretion of vascular endothelial growth factor (VEGF), macrophage migration inhibitory factor (MIF), and various pro-inflammatory cytokines (interleukin, IL; chemokine C-X-C motif ligand, CXC; granulocyte-colony stimulating factor, G-CSF; intercellular adhesion molecule, ICAM; chemokine C-C motif ligand, CCL) were compared among treatment groups at baseline (0?h) and after 8?h, 24?h, and 72?h of treatment. Changes in HACM protein expression were determined by quantitative proteomic analysis after 48?h of exposure. Compared to constant normoxia and mild hypoxia, constant hyperoxia resulted in a higher TB-positive cell count, greater release of LDH, and elevated secretion of VEGF, MIF, IL-1β, IL-6, IL-8, CXCL-1, CXCL-10, G-CSF, ICAM-1, CCL-3, and CCL-5. Cellular inflammation and cytotoxicity gradually increased and was highest after 72?h of constant and intermittent hyperoxia. Quantitative proteomic analysis revealed that hypoxic and hyperoxic O2 exposure differently altered the expression levels of proteins involved in cell-cycle regulation, energy metabolism, and cell signaling. In conclusion, constant and intermittent hyperoxia induced inflammation and cytotoxicity in HACMs. Cell injury occurred earliest and was greatest after constant hyperoxia, but even relatively brief repeating hyperoxic episodes induced a substantial inflammatory response. © 2016 by the Shock Society

Druml W.,Vienna University Hospital
Current Opinion in Critical Care | Year: 2014

Purpose of review Acute kidney injury (AKI) is a frequent and serious event associated with a high rate of complications, with an increased risk of progression to multiple organ dysfunction and excessive 'attributable' mortality. AKI affects all physiologic functions and organ systems with interrelated mechanisms, including the 'classical' consequences of the uremic state, the inflammatory nature of AKI per se and resulting systemic effects, the modulating effect of AKI in the presence of an (inflammatory) underlying disease process and the multiple untoward effects induced by renal replacement therapy (RRT) and anticoagulation. Recent findings A rapidly increasing body of evidence is clarifying these systemic effects that are the reflection of a broad common pathology that ultimately results in an 'augmented' inflammation and impairment of immunocompetence. This includes the release of cytokines and inflammatory mediators, increase in oxidative stress, activation of various immune cells, neutrophil extravasation, generalized endothelial injury, increased vascular permeability and tissue oedema formation. Summary These systemic phenomena associated with AKI induce distant organ injury affecting all organ systems with clinically the most relevant effects being exerted on the lungs, the intestines and liver and the heart and predispose the progression to multiple organ dysfunction syndrome and death. Currently available renal replacement therapy modalities are incapable of compensating for these systemic consequences of AKI. © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins.

Schwarz C.,Vienna University Hospital
Transplantation | Year: 2016

BACKGROUND: Allogeneic hematopoietic stem cell transplantation (HSCT) can lead to donor-specific tolerance. Patients reported in the literature that underwent kidney transplantation (KT) after a previous HSCT from the same haploidentical donor typically received short-term immunosuppression, mainly for safety reasons and concerns of triggering graft-versus-host disease. METHODS: We describe the case of a 22-year-old patient who developed chronic kidney failure after receiving haploidentical HSCT from his father for the treatment of metastatic rhabdomyosarcoma. Five years after HSCT, he received a preemptive kidney transplant from his father. Steroid treatment, which had been prescribed for the underlying kidney disease, was withdrawn within 2 months posttransplant, and no de novo immunosuppression was given. Donor-specific tolerance was assessed with mixed lymphocyte reaction and INF-γ ELISPOT before (D0) and after KT (D9). Furthermore, the exact level of donor-derived T cells was measured with real-time polymerase chain reaction before and 1 year after KT. RESULTS: In vitro assays (mixed lymphocyte reaction and ELISPOT) revealed donor-specific tolerance before and after transplantation, respectively. The number of recipient-derived T cells was low before KT and virtually did not change over time (0.0139% ± 0.0039 and 0.0120% ± 0.0067; P = NS). Graft function was excellent throughout the follow-up (36 months post KT: serum creatinine, 1.18 mg/dL). Protocol biopsies performed 1 and 12 months after transplantation confirmed the absence of rejection. CONCLUSIONS: This is one of the first cases of kidney transplantation from the same donor after previous haploidentical HSCT with a corticosteroid taper alone. Our results suggest that immunosuppression can be avoided in such cases. Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.

Valentin A.,Vienna University Hospital
Current Opinion in Critical Care | Year: 2010

Purpose of review Intensive care patients are per definition at risk for an unfavourable outcome while at the same time being exposed to the risks of a very complex and invasive process of care. This review addresses this extrinsic risk with respect to causative factors and strategies for risk reduction. Recent findings A growing amount of evidence shows that the actual risk of an unfavourable outcome in critically ill patients depends on the quality of the process of care. Several domains have been identified in which changes in infrastructure, process, and culture can result in a substantial risk reduction and increased patient safety. Important examples refer to work environment and workload of intensive care professionals, safety climate, information flow, and continuity of care. Recent studies have demonstrated that routine procedures in intensive care are amenable to considerable improvement. Summary This review discusses recent findings related to the reduction of risk in critically ill patients with respect to the process of intensive care medicine and the conditions under which that care is provided. Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

Hoke M.,Vienna University Hospital
Swiss medical weekly | Year: 2011

Dental status and oral hygiene are associated with progression of atherosclerosis in patients with carotid stenosis. It remains unclear whether dental disease is a risk factor for mortality in these patients. We evaluated the bearing of dental disease on mortality among patients with asymptomatic carotid atherosclerosis. Three World Health Organization-validated indices in 411 patients with asymptomatic carotid atherosclerosis were evaluated, measuring DMFT (decayed, missing, filled teeth) for dental status, CPITN (community periodontal index for treatment needs) for periodontal status and SLI (Silness-Löe Index) for oral hygiene respectively. Patients were prospectively followed for median 6.2 years (IQR 5.8 to 6.6 years) for all-cause mortality. During follow-up, 107 (26%) deaths occurred (74 cardiovascular causes). DMFT and SLI, but not CPITN, showed a significant and gradual association with mortality. For continuous variables, the adjusted hazard ratios (HR) for death were 1.06 (95% CI 1.0 to 1.12; p = 0.04) for DMFT, and 1.43 (95% CI, 1.01 to 2.03; p = 0.04) for SLI respectively. Edentulousness was a significant risk factor for death (adjusted HR 1.99, 95% CI, 1.18 to 3.02; p = 0.008). Dental status and oral hygiene were associated with mortality in patients with carotid atherosclerosis regardless of conventional cardiovascular risk factors.

Valentin A.,Vienna University Hospital
Current Opinion in Critical Care | Year: 2013

PURPOSE OF REVIEW: The very complex process of intensive care is accompanied by a not unexpected accumulation of risk for error and adverse events. The present review addresses strategies to decrease care errors in several domains of daily intensive care practice. RECENT FINDINGS: Strategies to decrease care errors now focus on a systematic approach by identifying latent system failures and change the design of the care process in such a way that inevitable human errors are prevented or their consequences are mitigated. Recent examples refer to the standardization of processes, adaptation to cognitive limitations of human beings, optimization of working conditions, and the increasing use of supporting information technologies. The development of a safety climate constitutes a key element and apparently contributes to reduction of medical errors in ICUs. SUMMARY: The present review discusses recent approaches aimed to decrease care errors in ICUs. A growing body of evidence demonstrates that a system based approach with the change of process characteristics and the development of a safety climate is most essential in the effort to increase patient safety. © 2013 Wolters Kluwer Health Lippincott Williams & Wilkins.

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