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Die Etablierung eines nationalen Dokumentationsstandards in deutschen Notaufnahmen ist dringend notwendig und steht seit vielen Jahren aus. Dieser ist die Grundlage, um das geforderte Benchmarking und die externe Qualitatssicherung von Notaufnahmen zu gewahrleisten. Mit dem DIVI-Notaufnahmeprotokoll V2015.1 existiert ein konsentierter interdisziplinarer und interoperabler Dokumentationsstandard fur deutsche Notaufnahmen.

Nach einer fraglichen Bagatellverletzung im Bereich der Groszehe bei der Gartenarbeit kommt es bei einem 58-jahrigen Patienten innerhalb von 24 Stunden zu einer ausgepragten Schmerzsymptomatik im linken Unterschenkel sowie plotzlichem Fieber mit Schuttelfrost. Bei Aufnahme in der chirurgischen Klinik zeigten sich eine etwa doppelt handtellergrose livide Hautverfarbung mit tastbarem Hautemphysem des Unterschenkels bis zum distalen Drittel des Oberschenkels sowie ein Kompartmentsyndrom des Unterschenkels (⊡ Abb. 27.1). Innerhalb von einer Stunde nach Aufnahme verstarkt sich die Symptomatik mit ausgepragter Blasenbildung am ventralen Unterschenkel (⊡ Abb. 27.2). Klinisch fallen eine Tachykardie und eine diskrete Schweisneigung auf. Anamnestisch sind bei dem Patienten auser einer Tachyarrhythmia absoluta und einem Insulin-pflichtigen Diabetes mellitus Typ 2 keine weiteren Vorerkrankungen bekannt.

Severe microcirculatory disturbances due to endothelial cell damage and leukocyte adherence during reperfusion of transplanted livers are considered to contribute to early graft failure. Since the degree of reperfusion injury after liver transplantation depends on the length of preservation time and the solution used for preservation, the aim of our study was to assess three solutions with respect to microvascular perfusion and leukocyte adhesion. Therefore, rat livers were stored up to 24 h in Euro-Collins (EC), University of Wisconsin (UW), or histidin-tryphtophan-ketoglutarate (HTK) solutions prior to orthotopic transplantation. The livers were studied in situ 60 min postoperatively using intravital fluorescence video microscopy. Using simple syringe flushing (10 ml), sinusoidal perfusion decreased below 50% in EC preserved livers after 8 h preservation, in HTK preserved livers after 16 h preservation, and remained higher than 70% in livers preserved in UW up to 24 h. Permanent adhesion of leukocytes was increased more rapidly in organs after 1, 8, 16, and 24 h preservation in HTK (16%, 15%, 34%, and 49.7% ± 4.7%) compared to those preserved in UW (15%, 18%, 17%; and 32.7% ±3.3%; P < 0.05). Using a 10-fold volumn of the organ weight of HTK solution during the harvesting procedure, with an 8 min equilibration period, sinusoidal perfusion (39.6 ±4.7%) and leukocyte adhesion (42.7 ±3.1%) were not improved after 24 h. In contrast, equilibration with a volumn of approximately 40-times the liver weight improved sinusoidal perfusion (70.8% ±2.7%; P < 0.01) and leukocyte adhesion (24.9% ±3.1%; P < 0.01) significantly. Thus, using HTK solution, simple flushing prior to long-term cold storage resulted in microcirculatory disturbances when compared to UW solution. Larger volumns of HTK solution with an additional equilibration period of 8 min, however, reduced leukocyte adhesion and improved sinusoidal perfusion to a similar degree as UW solution.

It has been shown recently that inclusion of the calcium channel blocker nisoldipine to University of Wisconsin (UW) solution significantly improves survival after rat liver transplantation. To further elucidate the mechanisms involved, rat livers were stored for 1 h in UW solution with or without the addition of 1.4 μM nisoldipine (Miles, West Haven, Conn., USA). The liver grafts were investigated in vivo 90 min after transplantation by intravital fluorescence microscopy. Sinusoidal perfusion was reduced in all sublobular regions of the liver in the UW group (e. g. portal area: 76.7 ± 2.1%) and in the nisoldipine group (85.8 ± 1.5%). Diameters of liver sinusoids were comparably reduced in the UW and nisoldipine groups indicating that nisoldipine did not cause vasodilatation. Adhesion of leukocytes, however, rose significantly after liver transplantation particularly in periportal regions (25.8 ±2.5%) compared to controls (17.1 ±2.8%; P < 0.05). Adhesion of leukocytes was reduced when nisoldipine was included in UW solution (13.3 ±1.7%; P < 0.05). Administration of latex particles, which were given in additional experimental groups, demonstrated an impressive increase in phagocytic activity of Kupffer cells after liver transplantation in periportal and pericentral areas (161 ±14% and 184 ±19% of controls). Phagocytosis was significantly reduced by nisoldipine in the periportal region (101 ± 10%; P < 0.01). Thus, the beneficial effect of nisoldipine was most pronounced in periportal regions, where the majority of Kupffer cells are located and leukocyte adhesion was at a maximum.