Der Internist
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The 1st revision of the S2k guideline on the prevention and follow-up care of sepsis, provided by the German Sepsis Society in collaboration with 17 German medical scientific societies and one self-help group provides state-of-the-art information on the effective and appropriate medical care of critically ill patients with severe sepsis or septic shock. The guideline recommendations may not be applied under all circumstances. It rests with the clinician to decide whether a certain recommendation should be adopted or not, taking into consideration the unique set of clinical facts presented in connection with each individual patient as well as the available resources.
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Sleep disordered breathing, especially obstructive sleep apnea, are common in cardiovascular disease. Negative hemodynamic effects are mediated by nocturnal ischemia and intrathoracal pressure swings. ⋯ Further on, clinical course of coronary artery disease seems to be influenced by nocturnal breathing disorders. Application of continuous positive airway pressure (CPAP) is effective in most of the patients and attenuates cardiodepressive hemodynamic effects of obstructive sleep apnea.
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In patients suffering from severe sepsis an impairment of cardiac function is seen constantly. Patients with septic shock often show a transient reduction of cardiac ejection fraction. Besides, a tremendous impairment of heart rate variability corresponding to a poor prognosis is often found. ⋯ The method of choice to quantify the degree of septic cardiomyopathy at the intensive care unit certainly is to determine cardiac output in relation to systemic vascular resistance. Unfortunately, clinical trials aiming to influence the causal pathogenesis of septic cardiomyopathy (inhibition of excess formation of nitric oxide, suppression of cytokine release etc.) were rather disappointing so far. Positive effects might be assumed for the administration of activated protein C thereby underlining the role of microcirculatory alterations in the development of septic cardiomyopathy.
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Case Reports
[Withdrawal in a patient with an implantable drug delivery system in spite of continuation of opiate therapy].
A male patient with severe chronic pain has been treated with a combined drug therapy scheme of morphine and clonidine. After cessation of clonidine the patient reported opiate-withdrawal symptoms with agitation, polyuria, diarrhea, and hyperalgesia. It is known that the combination of these two substances causes synergistic analgetic effects. The abrupt cessation of clonidine after a combined administration with morphine seems to lead to a relative decrease in opiate effects and furthermore excite opiate-withdrawal symptoms.