Med Klin
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Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) are the two most serious metabolic complications of diabetes mellitus (DM). These disorders can occur in both type 1 and type 2 DM. DKA is characterized by hyperglycemia, ketone body formation and metabolic acidosis. ⋯ The prognosis of both conditions is substantially worsened in patients > 65 years of age and in the presence of coma and hypotension. Mainstays of therapy are intravenous insulin and fluid replacement as well as the concomitant treatment of the precipitating factors. Improved patient education and implementation of measures such as home glucose and ketone monitoring might decrease the number of hospital admissions due to DKA and HHS, which are, in their majority, preventable).
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The progression of chronic kidney disease (CKD) is more than just a simple, creeping loss of kidney function finally resulting in end-stage renal disease (ESRD). First, the growing incidence of CKD implies an exploding socioeconomic burden. Second, clear evidence indicates that CKD is associated with an independent massive increase in the patient's cardiovascular risk. ⋯ Our current understanding of optimized antihypertensive and antiproteinuric therapy favors a multimodal treatment regimen. Reduction of proteinuria toward levels < 0.5 g per day would be ideal. By this intervention the risk for both ongoing renal function loss as well as the risk of cardiovascular disease can be markedly reduced.
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Initiation of effective cardiopulmonary resuscitation (CPR) at the earliest possible time is the most important determinant of prognosis for patients with prehospital cardiac arrest. Basic life support CPR, defibrillation by emergency medical systems or first responders as well as vasopressor drugs or antiarrhythmics are essential. ⋯ Technique and methods of resuscitation are ranging from CPR to additional drugs. Fast and consequent work is essential. Among the "chain of survival" there is an increased value of first responders.
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The future perspectives of cardiovascular intensive care medicine (CVICM) are affected by an ever increasing number of elderly (> 65 years), old (> 75 years) and very old (> 85 years) patients with the incidental clinical consequences, by an increase in inpatient days due to the increasing number of patients who have to be treated despite cost pressure, and by the attempts to integrate CVICM into one interdisciplinary intensive care unit (ICU) including medical and surgical patients, although proof of equal or even superior outcome, process or structural quality is lacking presently. To overcome all the problems mentioned, CVICM must develop from a mainly consensus-oriented to a more evidence-oriented medicine; CVICM must find ways to improve the poorly validated hemodynamic monitoring concept by pulmonary artery catheter and look for additional, less invasive monitoring techniques and better monitoring parameters; CVICM must support the search for new and hopefully better pharmacotherapeutic agents and cardiovascular assist devices as presently available to support the failing heart and the impaired vascular system; and CVICM must also learn to control noncardiac processes like inflammation and multi-organ failure, which often are responsible for the fatal outcome of the ICU patient with cardiovascular disease. Real challenges for the cardiovascular intensivist are refractory shock and refractory septic cardiomyopathy, these cardiovascular disease entities being responsible for every other fatality in the wake of severe sepsis and septic shock. To handle these tremendous challenges of CVICM, training of the young cardiologists in CVICM must be intensified, and much more attention to cardiovascular topics and techniques must be paid when training our colleagues in medical intensive care medicine.
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Noninvasive ventilation refers to mechanical respiratory assist not requiring an endotracheal airway. Potential advantages include the reduction of complications resulting from intubation and invasive long-term mechanical ventilation and possibly a reduced time demand on medical personnel in the long run. Patients with additional severe organ failure, lacking ability to cooperate or high risk of aspiration are not suitable for noninvasive ventilation. ⋯ For pulmonary edema noninvasive CPAP (continuous positive airway pressure) reduces the symptoms and the need for intubation, although studies have not demonstrated a reduction in mortality. In other forms of acute respiratory failure noninvasive ventilation may be helpful, but its final role still has to be established. In these patients a trial of noninvasive ventilation appears to be safe as long as patients are carefully selected and intubation is not prolonged.