Background In mechanically ventilated patients with acute respiratory distress syndrome (ARDS), electrical impedance tomography (EIT) provides information on alveolar cycling and overdistension as well as assessment of recruitability at the bedside. We developed a protocol for individualization of positive end-expiratory pressure (PEEP) and tidal volume (VT) utilizing EIT-derived information on recruitability, overdistension and alveolar cycling. The aim of this study was to assess whether the EIT-based protocol allows individualization of ventilator settings without causing lung overdistension, and to evaluate its effects on respiratory system compliance, oxygenation and alveolar cycling. Methods 20 patients with ARDS were included. Initially, patients were ventilated according to the recommendations of the ARDS Network with a VT of 6 ml per kg predicted body weight and PEEP adjusted according to the lower PEEP/FiO2 table. Subsequently, ventilator settings were adjusted according to the EIT-based protocol once every 30 min for a duration of 4 h. To assess global overdistension, we determined whether lung stress and strain remained below 27 mbar and 2.0, respectively. Results Prospective optimization of mechanical ventilation with EIT led to higher PEEP levels (16.5 [14–18] mbar vs. 10 [8–10] mbar before optimization; p = 0.0001) and similar VT (5.7 ± 0.92 ml/kg vs. 5.8 ± 0.47 ml/kg before optimization; p = 0.96). Global lung stress remained below 27 mbar in all patients and global strain below 2.0 in 19 out of 20 patients. Compliance remained similar, while oxygenation was significantly improved and alveolar cycling was reduced after EIT-based optimization. Conclusions Adjustment of PEEP and VT using the EIT-based protocol led to individualization of ventilator settings with improved oxygenation and reduced alveolar cycling without promoting global overdistension. Trial registrationThis study was registered at clinicaltrials.gov (NCT02703012) on March 9, 2016 before including the first patient.

reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. carbon dioxide 30 [27][28][29][30][31][32][33][34][35] mmHg and median temperature 37.1 [36.8-37.3]°C. After removal of artefacts, the mean monitoring time was 22 h08 (8 h54). All patients had impaired cerebral autoregulation during their monitoring time. The mean IAR index was 17 (9.5) %. During H 0 H 6 and H 18 H 24 , the majority of our patients; respectively 53 and 71 % had an IAR index > 10 %. Conclusion According to our data, patients with septic shock had impaired cerebral autoregulation within the first 24 hours of their admission in the ICU. In our patients, we described a variability of distribution of impaired autoregulation according to time. ReferencesSchramm P, Klein KU, Falkenberg L, et al. Impaired cerebrovascular autoregulation in patients with severe sepsis and sepsis-associated delirium. Crit Care 2012; 16: R181. Aries MJH, Czosnyka M, Budohoski KP, et al. Continuous determination of optimal cerebral perfusion pressure in traumatic brain injury. Crit. Care Med. 2012.

Perkutane transhepatische CholangiographieIhre Bedeutung für die Lokalisierung des Abflußhindernisses beim Verschlußikterus nach Oberbauchoperationen Beim Verschlußikterus ist die Differenzierung des Hindernisses ohne die perkutane transhepatische Darstellung des intra-und extrahepatischen Gallenwegssystems nur in Ausnahmefällen möglich. Konventionelle röntgenologische Verfahren bringen nur selten Klärung. Nach intravenöser Verabreichung von Kontrastmittel gelingt schon bei einem Bilirubinwert von 3 bis 4 mg/lOO ml keine ausreichende Darstellung der Gallenwege mehr (2, 4, 7). Selbst nach komplikationsfreien Eingriffen am extrahepatischen Gallenwegssystem ist erst nach zwei bis drei Monaten wieder mit einer ausreichenden Darstellung des Ductus hepatocholedochus bei intravenöser Gabe von Kontrastmittel zu rechnen. Nach Oberbauchoperationen, speziell nach Eingriffen am extrahepatischen Gallenwegssystem, bleibt deshalb die perkutane transhepatische Cholangiographie die einzige, zuverlässig erfolgversprechende diagnostische Möglichkeit, einen Verschlußikterus zu differenzieren oder auszuschließen.Ohne sie gelang bei keinem der von uns untersuchten 26 Patienten eine ausreichende präoperative Lokalisierung des Hindernisses.Wir benutzen wie Wenz (7) dazu eine 14 cm lange Aortographienadel ohne Kunststoffkatheter und bevorzugen den lateralen Zugang im rechten neunten oder zehnten Interkostairaum in der mittleren Axillarlinie. Die Untersuchung erfolgt im allgemeinen unmittelbar vor der geplanten Operation, zumindest jedoch in Operationsbereitschaft.Redaktion:.

BackgroundIn mechanically ventilated patients with acute respiratory distress syndrome (ARDS), electrical impedance tomography (EIT) provides information on alveolar cycling and overdistension as well as assessment of recruitability at the bedside. We developed a protocol for individualization of positive end-expiratory pressure (PEEP) and tidal volume (VT) utilizing EIT-derived information on recruitability, overdistension and alveolar cycling. The aim of this study was to assess whether the EIT-based protocol allows individualization of ventilator settings without causing lung overdistension, and to evaluate its effects on respiratory system compliance, oxygenation and alveolar cycling. Methods20 patients with ARDS were included. Initially, patients were ventilated according to the recommendations of the ARDS-Network with a VT of 6 ml per kg predicted body weight and PEEP adjusted according to the fraction of inspired oxygen. Subsequently, ventilator settings were adjusted according to the EIT-based protocol once every 30 minutes for a duration of 4 hours. To assess global overdistension, we determined whether lung stress and strain remained below 27 and 2.0, respectively. ResultsWe found that prospective optimization of mechanical ventilation with EIT led to global lung stress below 27 mbar in all patients and global strain below 2.0 in 19 out of 20 patients. Compliance remained similar while oxygenation was significantly improved and alveolar cycling was reduced after EIT-based optimization.ConclusionsAdjustment of PEEP and VT using the EIT-based protocol led to individualization of ventilator settings with improved oxygenation and reduced alveolar cycling without promoting global overdistension. Trial registrationThis study was registered at clinicaltrials.gov (NCT02703012) on March 9, 2016 before including the first patient.