Zusammenfassung Das akute Leberversagen (ALV) ist ein seltenes, aber lebensbedrohliches Zustandsbild. Charakteristisch ist das rasche Auftreten eines schweren Leberschadens mit hepatozellulärer Nekrose und eingeschränkter Leberfunktion. Bei weiterhin hoher Mortalität ist ein frühzeitiges Erkennen und Einleiten einer ursachenspezifischen unterstützenden sowie v. a. intensivmedizinischen symptomatischen Therapie essenziell. Durch Fortschritte im Bereich der intensivmedizinischen Behandlung von Patienten mit akutem Leberversagen sowie der Lebertransplantation konnte das Überleben deutlich verbessert werden.

Acute liver failure (ALF) is a rare condition with fatal outcome. Characteristic is rapid onset of liver damage without preexisting liver diseases, including hepatic encephalopathy and coagulopathy. Early and correct diagnosis is essential for further management of patients, since diagnosis impacts therapy choice. Survival of patients with ALF has improved dramatically due to advances in critical care medicine and the use of liver transplantation.

Einleitung: Veranderungen der Hamostase finden sich haufig bei Patienten mit Leberzirrhose. Der „disseminated intravascular coagulation score“ (DIC score) errechnet sich aus Routine-Gerinnungsparametern (Thrombozytenzahl, D-Dimere, Fibrinogen und Prothrombinzeit/-index) und ist ein bekannter Uberlebenspradiktor bei kritisch kranken Patienten. Aufgrund der Haufigkeit von „pathologischen“ Gerinnungsparametern bei Patienten mit Leberzirrhose ist bislang jedoch unklar, ob der DIC score eine prognostische Aussagekraft bei diesen Patienten besitzt. Ziele: Ziel dieser Studie ist die Bestimmung und die Beurteilung der Anwendbarkeit des DIC Score bei kritisch kranken Patienten mit Leberzirrhose. Methodik: Zirrhose-Patienten, die an der Intensivstation zur Aufnahme gelangten, wurden in dieser Arbeit analysiert. Detaillierte Laboruntersuchungen inklusive Gerinnungsanalysen wurden bei Aufnahme durchgefuhrt und der DIC Score berechnet. Das 28-Tage-Uberleben der Patienten wurde erhoben. Ergebnis: Hundertfunfzig Intensivstations-Aufnahmen mit Leberzirrhose wurden analysiert. Neununddreisig Prozent waren weiblich. Das mediane Alter betrug 56 (IQR 49 – 63) Jahre. Der mediane SOFA Score bei Aufnahme betrug 9 (6 – 13), der mediane MELD score 26 (IQR 18 – 36). Die 28-Tage-Mortalitat lag bei 59%. Der mediane DIC score bei Aufnahme betrug 5 (IQR 4 – 6). „Overt DIC“ (DIC Score ≥5) fand sich bei 65% der Aufnahmen. Bezogen auf die 28-Tage-Mortalitat war der DIC Score bei Nicht-Uberlebenden signifikant hoher als bei Uberlebenden (5 (IQR 4 – 7) vs. 4 (IQR 3 – 6); p < 0.01). Die AUROC fur den DIC Score hinsichtlich der Vorhersage der 28-Tage-Mortalitat war 0.68 (95% CI 0.59 – 0.77). Das Vorhandensein einer „Overt DIC“ bei Aufnahme war signifikant mit der 28-Tage-Mortalitat assoziiert (OR = 3.4 (95% CI 1.69 – 6.84), p < 0.01). Die 28-Tage-Mortalitatsrate bei Aufnahmen mit Zirrhose und „Overt DIC“ betrug 70% verglichen zu 40% bei Patienten mit einem DIC score < 5. Schlussfolgerung: Veranderungen der Hamostase finden sich in der Mehrzahl der Patienten mit Leberzirrhose auf der Intensivstation. Der DIC score ist ein Pradiktor fur das 28-Tage-Uberleben bei kritisch kranken Patienten mit Leberzirrhose.

The disseminated intravascular coagulation (DIC) score is a predictor of outcome in critically ill patients [1]. Yet, disturbances of coagulation are a common finding in patients with liver cirrhosis. Thus, the prognostic value of the DIC score and its subcomponents in patients with liver cirrhosis is unclear.

Objective. Endotracheal intubation (ET) in intensive care unit (ICU) patients is generally regarded more challenging than elective intubations in the operating room. This is in consequence of the general emergency situation with limited time, instability of oxygenation and hemodynamics as well as the interfering underlying diseases. Despite these challenging conditions in ICU, trainees are often the initial operators performing ET. Since non-anesthesiologist intensivists with limited experience in ET run most of the non-surgical ICUs it is of exceptional importance to identify patients with predictable difficult ET in advance to prepare for a difficult airway scenario and thus avoid severe complications. Method. Recently, the MACOCHA score was forwarded to identify difficult ETs preemptively on the basis of specific parameters including particularly the profession of the operator as well as patient airway characteristics. In this prospective observational, single center study we used a modified MACOCHA score in order to evaluate intubation performance of non-anesthesiologist ICU trainees in an interdisciplinary medical ICU. A total of 134 consecutive ET’s were analyzed. Results. We show that (i) ET could be performed safe and without fatal complications in all cases, (ii) a modified MACOCHA score = 8 predicts failure of ICU trainees, (iii) availability of ear-nose and throat (ENT) physician and anesthesiologist is required to warrant successful management of difficult airways. Conclusion. Our findings are a further step to implement the MACOCHA score into the standard admission procedure of an ICU to early identify those patients in whom additional support is needed in case of ET. Spezielle Probleme der klinischen Infektiologie

BACKGROUND:Long-term outcome of chronic hepatitis C patients with successful viral eradication seems to be promising.AIM:To evaluate mortality, incidence of hepatocellular carcinoma (HCC), liver failure and liver transplantation in sustained virological responders (SVR) and non-SVR patients with different stages of fibrosis.METHODS:Seven hundred and fourteen patients with a follow-up of 7.2 (1-21.1) years (age: 51.4 ± 12.0 years, 276 female, IFN-monotherapy: n = 19, IFN/RBV: n = 122, peg-IFN/RBV: n = 573, SVR: 551, non-SVR: 163) were studied. Two hundred and ten of 540 patients with a liver biopsy prior to treatment had advanced stages of fibrosis (Metavir F3/F4).RESULTS:Forty-eight patients died during follow-up, 15 with SVR and 33 without (P < 0.001). Five- and 10-year mortality rates were 1.8% (10/551) and 2.7% (15/551) in the SVR group and 8.6% (14/163) and 19.1% (31/163) in the non-SVR patients (P < 0.001). In 29 patients, decompensation of liver disease [SVR: 9 (1.6%) vs. non-SVR: 20 (12.3%); P < 0.001] occurred and in 29 patients, HCC developed during follow-up [SVR: 10 (1.8%) vs. non-SVR: 19 (11.7%); P < 0.001]. Non-SVR was an independent predictor for developing (i) HCC [HR: 2.36 (95% CI: 1.07-5.23; P = 0.034], (ii) liver-related complications [HR: 2.62; (95% CI: 1.18-5.81; P = 0.018] and (iii) mortality (HR: 3.46; 95% CI: 1.91-6.29; P < 0.001). For patients with early stages of fibrosis (F0-F2), a survival benefit of SVR patients could not be demonstrated.CONCLUSIONS:Successful anti-viral therapy decreases mortality, incidence of hepatocellular carcinoma and liver failure in patients with advanced fibrosis. However, hepatocellular carcinoma development or liver failure are not prevented completely, and further follow-up of patients is advisable.

Hepatic impairment is found in up to 20 % in critically ill patients. Hypoxic/ischemic hepatitis (HH) is a diffuse hepatic damage associated with high morbidity and mortality. Indocyanine green plasma disappearance rate (ICG-PDR) is an effective tool assessing liver function in acute and chronic hepatic diseases. Aim of this study was to evaluate the prognostic impact of ICG-PDR in comparison to established parameters for risk stratification.

Clostridium species are gram-positive, anaerobic, spore-forming bacteria and some species have pathogenic nature. There is limited data regarding Clostridium non-difficile infection in critically ill patients available. Symptoms of infection are often non-specific, which leads to delayed diagnosis and therapy initiation in these patients.

Sudden cardiac arrest (CA) is one of the leading causes of death in adults in many parts of the world [1]. Every year estimated 350.000 to 700.000 people in Europe are suffering CA and receive cardiopulmonary resuscitation (CPR) [2]. To date, there is no data available on CA and CPR in patients with liver cirrhosis.

The disseminated intravascular coagulation (DIC) score is a predictor of outcome in critically ill patients [1,2]. Yet disturbances of coagulation and hemostasis, as reflected by the DIC score, are a common finding in patients with liver cirrhosis. Thus, it is unclear whether the DIC score has prognostic value in critically ill patients with liver cirrhosis. The aim of this study was to assess the applicability and prognostic impact of the DIC score in critically ill patients with liver cirrhosis.

Summary Background Genetic factors can play an important role for treatment response and disease progression in chronic viral hepatitis. Aim To review the influence of host genetic factors on the clinical course as well as on treatment response in patients with viral hepatitis. Methods Review of the literature. Results A landmark genome‐wide association study ( GWAS ) identified polymorphisms in the IL28B gene on chromosome 19 (19q13.13) associated with response to therapy with pegylated interferon‐α ( PEG‐IFN ) and ribavirin ( RBV ) and spontaneous viral clearance in acute hepatitis C. Furthermore, IL28B genotype is associated with changes of lipid metabolism and insulin resistance. A further GWAS demonstrated that ITPA genetic variants protect HCV genotype 1 patients from RBV ‐induced anaemia. Another polymorphism in the patatin‐like phospholipase domain containing 3 ( PNPLA3 ) is associated with hepatic steatosis. Difficult‐to‐treat hepatitis C patients homozygous for GG had an up to five‐fold lower chance of viral clearance on PEG / RBV than non‐ GG patients. In chronic hepatitis B patients treated with PEG‐IFN several retrospective analyses of IL28B rs12980275 and rs12979860 genotypes yielded conflicting results which can be explained by the heterogeneity between the study populations. Some variants of the HLA ‐ DP locus ( HLA‐DPA1 A allele and HLA‐DPB1 ) protect against progression of chronic hepatitis B infection. Conclusions The determination of IL28B polymorphisms may be useful to individualise treatment options when using PEG / RBV based therapies for chronic hepatitis C infection. In contrast, so far identified genetic factors play only a minor role in chronic hepatitis B infection.