Der Internist
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In the majority of the cases cerebrovascular disease is caused by atherosclerosis. Duplexsonography is the diagnostic tool of first choice. Management of cardiovascular risk factors is of paramount importance in secondary prevention of atherosclerotic vascular complications. ⋯ Asymptomatic patients with >60% stenosis benefit from revascularisation if the perioperative risk for death or stroke is below 3%. The optimal revascularization strategy highly depends on the expertise of the local surgeon or endovascular specialist. In younger patients with cerebrovascular disease rare causes such as dissection, large vessel arteritis, fibromuscular dysplasia or vasospasms have to be considered.
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This article deals with specific aspects of the patient with sepsis and his treatment. With adequate therapy (antibiotics started within the first hour, early goal-directed therapy) initiated as early as possible, the patient with community-aquired severe sepsis in the emergency department has a considerable better chance to survive than the patient with prolonged severe sepsis in the ICU. The average age of patients with severe sepsis and septic shock treated at the ICU is rising, with consequences like oligosymptomatic presentation, altered pharmakokinetics according to older-age-induced reduced organ functions and prolonged stay at the ICU due to comorbidity. ⋯ In an animal sepsis model activation of the estrogen receptor beta improves prognosis. Within six months after having survived severe sepsis, morbidity and mortality is still increased. Taking care for the patient in a post-ICU outpatient department during this time will help to recognize these problems and to effectively treat the patient as soon as possible.
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Septic shock is not only a circulatory shock but is also a cardiac shock, the consequence of a potentially reversible heart impairment known as septic cardiomyopathy. Disturbances of macrocirculation as well as microcirculation, an individually heterogeneous reduction of cardiac function, and an extensive impairment of demand-oriented regulation of heart function characterize the septic shock state. ⋯ The intensity of circulatory as well as of cardiac impairment correlates with an unfavorable prognosis. Treatment of septic circulatory shock and of septic cardiomyopathy is predominantly symptomatic; first causal approaches are under investigation.
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Severe sepsis and septic shock have an increasing incidence but an unchanged mortality. It has been demonstrated that the time until the start of supportive therapy affects the progress of multiorgan failure and patient outcome. ⋯ The use of starches for volume resuscitation, low-dose dopamine and hydrocortison as well as an intensive insulin protocol for restoration of euglycemia is not recommended. The German Competence Network Sepsis (SepNet) is currently studying further relevant questions.
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The high mortality and morbidity of severe sepsis and septic shock had not been reduced during the two recent decades, despite a number of advances in the field of supportive and adjunctive sepsis therapies. The reason might be that important steps towards overcoming of sepsis - early diagnosis, the surgical resection of the infectious focus and an adequate antibiotic treatment - at present are still suboptimal and have to be improved. However, worldwide growing resistances of pathogens against the common antibiotics are detected. ⋯ Therefore, sepsis treatment must be focused on prevention of infection, and on an optimised application of current antibiotic substances. The key factors are a broad, high dose, and early applicated initial treatment, a de-escalation strategy according to the clinical course supported by the application of novel molecular markers, and - with exceptions - a limitation of treatment to 7 to 10 days. A closer cooperation between microbiologists, infection control specialists and clinical infectious disease consultants may be a key factor to overcome the raising problems in the future.