Search

The measurement of quality indicators supports quality improvement initiatives. The German Interdisciplinary Society of Intensive Care Medicine (DIVI) has published quality indicators for intensive care medicine for the fourth time now. After a scheduled evaluation after three years, changes in several indicators were made. Other indicators were not changed or only minimally. The focus remained strongly on relevant treatment processes like management of analgesia and sedation, mechanical ventilation and weaning, and infections in the ICU. Another focus was communication inside the ICU. The number of 1ndicators remained the same. The development method was more structured and transparency was increased by adding new features like evidence levels or author contribution and potential conflicts of interest. These quality indicators should be used in the peer review in intensive care, a method endorsed by the DIVI. Other forms of measurement and evaluation are also reasonable, for example in quality management. This fourth edition of the quality indicators will be updated in the future to reflect the recently published recommendations on the structure of intensive care units by the DIVI.

Background: Mechanical chest compression devices are commonly used providing a constant force and frequency of chest compression during cardiopulmonary resuscitation. However, there are currently no recommendations on ventilation during cardiopulmonary resuscitation with a mechanical chest compression device using continuous mode. An effective method for ventilation in such scenarios might be a triggered oxygen-powered resuscitator.Methods: We report seven cardiopulmonary resuscitation cases from the Munich Emergency Medical Service where mechanical chest compression devices in continuous mode were used with an oxygen-powered resuscitator. In each case, the resuscitator (Oxylator) was running in automatic mode delivering a breath during the decompression phase of the chest compressions at a frequency of 100 per minute. End-tidal carbon dioxide and pulse oximetry were measured. Additional data was collected from the resuscitation protocol of each patient.Results: End-tidal carbon dioxide was available in all cases while oxygen saturation only in four. Five patients had a return of spontaneous circulation. Based on the end-tidal carbon dioxide values of each of the cases, the resuscitator did not seem to cause hyperventilation and suggests that good-quality cardiopulmonary resuscitation was delivered.Conclusions: Continuous chest compressions using a mechanical chest compression device and simultaneous synchronized ventilation using an oxygen-powered resuscitator in an automatic triggering mode might be feasible during cardiopulmonary resuscitation.

The current S3 guideline, "Positioning Therapy and Mobilization of Critically Ill Patients in Intensive Care Units", introduces methodological changes and substantive updates compared to the previous version. Additionally, new evidence-based insights with specified PICO questions have been integrated, aiming for a more precise application of recommendations in clinical practice and thus enhancing the care of critically ill patients.A notable aspect is the more nuanced approach to early mobilization, which is recommended to commence within the first 72 hours of ICU admission. A staged concept and score-based mobilization schema facilitate improved patient rehabilitation. Mobilization should be standard of care, i.e., immobilization should be ordered by the physician. The guideline provides suggestions for the duration and additional mobilization measures to ensure patients stand, transfer actively from bed to chair, or walk as frequently as possible. These recommendations apply even during ECMO therapy, highlighting the importance of early mobilization.Further updates include semi-recumbent positions of at least 40° in intubated patients, with careful consideration of potential side effects. Continuous lateral rotation therapy (CLRT) is not advised due to the progress in intensive care therapy, shifting from deep sedation toward responsive patient management.Prone positioning (PP) involves rotating the patient 180° onto the ventral side. It is recommended as a therapeutic option for invasively ventilated patients with ARDS and impaired arterial oxygenation (PaO 2 /FiO 2 <150mmHg), with a recommended minimum duration of 12 hours, ideally 16 hours. Special recommendations apply, for example, to COVID-19 patients with acute hypoxemic respiratory failure, where awake proning should be considered.Additionally, new chapters have been introduced focusing on assistive devices and neuromuscular electrical stimulation., Competing Interests: C. Hermes: VG Wort Lizenzgebühren. Bezahlung oder Honorare für Vorträge, Präsentationen, oder Bildungsveranstaltungen: Atmos, Getinge, Arjo, TapMed. Reisekostenerstattung für wissenschaftliche Vorträge durch DIVI; DGIIN; DBfK; GFO. Mitglied: DGIIN (Vorstand), DGF, DBfK, DIVI, DGP, Pflegekammer NRW (Vorstand). Peter Nydahl gibt an das es keinen COI im Zusammenhang mit dem Manuskript gibt. Julius J. Grunow gibt an das es keinen COI im Zusammenhang mit dem Manuskript gibt. Stefan J Schaller gibt an: erhielt Fördermittel und nicht-finanzielle Unterstützung von Reactive Robotics GmbH (München, Deutschland), ASP GmbH (Attendorn, Deutschland), STIMIT AG (Biel, Schweiz), ESICM (Genf, Schweiz), Fördermittel, persönliche Honorare und nicht-finanzielle Unterstützung von Fresenius Kabi Deutschland GmbH (Bad Homburg, Deutschland), Fördermittel aus dem Innovationsfond des Gemeinsamen Bundesausschusses (G-BA), persönliche Honorare der Springer Verlag GmbH (Wien, Österreich) für Fortbildungszwecke und der Advanz Pharma GmbH (Bielefeld, Deutschland), nicht-finanzielle Unterstützung von nationalen und internationalen Gesellschaften (und deren Kongressveranstaltern) auf dem Gebiet der Anästhesiologie und Intensivmedizin, außerhalb der eingereichten Arbeit. Dr. Schaller hält in geringem Umfang Aktien von Alphabet Inc., der Bayer AG und der Siemens AG; diese Beteiligungen haben keine Entscheidungen bezüglich seiner Forschung oder dieser Arbeit beeinflusst., (Thieme. All rights reserved.)

The neurosurgical management of traumatic brain injury (TBI) plays a critical role in ensuring acute survival and mitigating secondary brain damage, which significantly impacts patients' quality of life. TBI is defined as an external force impacting the skull, leading to brain injuries and subsequent functional impairments. It is a leading cause of mortality and morbidity, particularly among young individuals. The initial clinical examination is crucial, with external signs like scalp injuries, hematomas, nasal fluid leakage, skull deformities, and neurological deficits providing important clues to injury patterns. Pupil examination is particularly critical, as mydriasis coupled with reduced consciousness may indicate an acute life-threatening increase in intracranial pressure (ICP), necessitating immediate neurosurgical intervention. TBI assessment often utilizes the Glasgow Coma Scale (GCS), classifying injuries as mild (GCS 13-15), moderate (GCS 9-12), or severe (GCS < 9). Even mild TBI can lead to long-term complications. TBI should be viewed as a disease process rather than a singular event. Primary brain damage results from shearing forces on the parenchyma, manifesting as contusions, hematomas, or diffuse axonal injury. Secondary brain damage is driven by mechanisms such as inflammation and spreading depolarizations. Treatment aims not only to secure immediate survival but also to reduce secondary injuries, with ICP management being crucial. Neurosurgical interventions are guided by cranial pathologies, with options including ICP monitoring, burr hole trepanation, craniotomy. In severe TBI cases with refractory ICP elevation, decompressive craniectomy may be performed as a last resort, significantly reducing mortality but often resulting in high morbidity and vegetative states, necessitating careful consideration of indications., Competing Interests: Erklärung zu finanziellen Interessen Forschungsförderung erhalten: ja, von einer anderen Institution (Pharma- oder Medizintechnikfirma usw.); Honorar/geldwerten Vorteil für Referententätigkeit erhalten: ja, von einer anderen Institution (Pharma- oder Medizintechnikfirma usw.); Bezahlter Berater/interner Schulungsreferent/Gehaltsempfänger: ja, von einer anderen Institution (Pharma- oder Medizintechnikfirma usw.); Patent/Geschäftsanteile/Aktien (Autor/Partner, Ehepartner, Kinder) an Firma (Nicht‐Sponsor der Veranstaltung): ja; Patent/Geschäftsanteile/Aktien (Autor/Partner, Ehepartner, Kinder) an Firma (Sponsor der Veranstaltung): nein Erklärung zu nichtfinanziellen Interessen Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Traumatic brain injury (TBI) is the main cause of death in people < 45 years in industrial countries. Minimising secondary injury to the injured brain is the primary goal throughout the entire treatment. Anaesthesiologic procedures aim at the reconstitution of cerebral perfusion and homeostasis. Both TBI itself as well as accompanying injuries show effects on cardiac and pulmonary function. Time management plays a crucial role in ensuring a safe anaesthesiologic environment while minimizing unnecessary procedures. Furthermore, growing medical drug pre-treatment demands for further knowledge e.g., in antagonization of anticoagulation., Competing Interests: Erklärung zu finanziellen Interessen Forschungsförderung erhalten: ja, von einer anderen Institution (Pharma- oder Medizintechnikfirma usw.); Honorar/geldwerten Vorteil für Referententätigkeit erhalten: ja, von einer anderen Institution (Pharma- oder Medizintechnikfirma usw.); Bezahlter Berater/interner Schulungsreferent/Gehaltsempfänger: ja, von einer anderen Institution (Pharma- oder Medizintechnikfirma usw.); Patent/Geschäftsanteile/Aktien (Autor/Partner, Ehepartner, Kinder) an Firma (Nicht‐Sponsor der Veranstaltung): ja; Patent/Geschäftsanteile/Aktien (Autor/Partner, Ehepartner, Kinder) an Firma (Sponsor der Veranstaltung): nein Erklärung zu nichtfinanziellen Interessen Research Committee Member der Europäischen Intensivgesellschaft (ESICM) Steuerungsgruppe des TifoNETs der DGAI, (Thieme. All rights reserved.)

Older people demonstrate a higher risk for the occurrence of peri- and postsurgical complications. A frequent risk factor for this is the prevalence of a status called "frailty". In general, this status can be reversed by adequate therapeutic and medical interventions. More, current evidence suggests that these measures, as part of a so-called prehabilitation, can reduce the risk for experiencing peri- and postsurgical complications and thus assist the rehabilitation process, increase quality of life, and avoid care dependency and a loss of autonomy of these patients. In this article, we describe the concept of prehabilitation, its options to adapt and design this new form of intervention, as well as presenting current evidence. An actual project and a case example on prehabilitation provide an example and outlook., Competing Interests: Erklärung zu finanziellen Interessen Forschungsförderung erhalten: nein; Honorar/geldwerten Vorteil für Referententätigkeit erhalten: ja, von einer anderen Institution (Pharma- oder Medizintechnikfirma usw.); Bezahlter Berater/interner Schulungsreferent/Gehaltsempfänger: ja, von einer anderen Institution (Pharma- oder Medizintechnikfirma usw.); Patent/Geschäftsanteile/Aktien (Autor/Partner, Ehepartner, Kinder) an im Bereich der Medizin aktiven Firma: nein; Patent/Geschäftsanteile/Aktien (Autor/Partner, Ehepartner, Kinder) an zu Sponsoren dieser Fortbildung bzw. durch die Fortbildung in ihren Geschäftsinteressen berührten Firma: nein Erklärung zu nichtfinanziellen Interessen Claudia Spies ist Mitglied der AWMF, der DFG, der Leopoldina, des IQWUC, von Cochrane, der APS und des IMPP. Alle anderen Autoren geben dass keine Interessenkonflikte bestehen., (Thieme. All rights reserved.)

Various limitations in everyday life can indicate a frailty syndrome. These limitations are not always directly visible and result from a wide variety of domains. Fried et al. described these limitations of different domains as frailty syndrome. This syndrome can be acutely worsened by different influencing factors. One major risk factor is an upcoming anesthesia and surgery. Frailty is associated with a significantly increased risk of peri- and postoperative complications. To avoid acute deterioration due to anesthesia and surgery, the concept of prehabilitation was developed. The aim is to specifically address the respective deficits and to develop an individual training concept together with the patient. Prehabilitation can significantly improve the risk of complications and the outcome of frail patients. In this context, it is important to establish routine screening in order to detect a frailty syndrome in everyday clinical practice and to create opportunities for prehabilitation., Competing Interests: Nils Daum: keine Interessenskonflikte. Jörn Kiselev: keine Interessenskonflikte. Stefan J. Schaller erhielt Zuschüsse von Reactive Robotics GmbH (München, Deutschland); Zuschüsse und nichtfinanzielle Unterstützung von STIMIT AG (Biel, Schweiz), Liberate Medical LLC (Crestwood USA), ESICM (Genf, Schweiz); Zuschüsse, persönliche Honorare und nichtfinanzielle Unterstützung von Fresenius Kabi Deutschland GmbH (Bad Homburg, Deutschland); persönliche Honorare der Springer Verlag GmbH (Wien, Österreich) für Fortbildungszwecke und der Advanz Pharma GmbH (Bielefeld, Deutschland); nichtfinanzielle Unterstützung von nationalen und internationalen Gesellschaften (und deren Kongressveranstaltern) auf dem Gebiet der Anästhesiologie und Intensivmedizin, außerhalb der eingereichten Arbeit. Dr. Schaller hält in geringem Umfang Aktien der Alphabeth Inc., der Bayer AG und der Siemens AG; diese Beteiligungen hatten keinen Einfluss auf Entscheidungen bezüglich seiner Forschung oder dieser Studie., (Thieme. All rights reserved.)

Background: Intensive care unit (ICU) acquired weakness is associated with reduced physical function, increased mortality and reduced quality of life, and affects about 43% of survivors of critical illness. Lacking therapeutic options, the prevention of known risk factors and implementation of early mobilization is essential. Robotic assistance devices are increasingly being studied in mobilization., Objective: This qualitative review synthesizes the evidence of early mobilization in the ICU and focuses on the advantages of robotic assistance devices., Results: Active mobilization should begin early during critical care. Interventions commencing 72 h after admission to the ICU are considered early. Mobilization interventions during critical care have been shown to be safe and reduce the time on mechanical ventilation in the ICU and the length of delirious episodes. Protocolized early mobilization interventions led to more active mobilization and increased functional independence and mobility at hospital discharge. In rehabilitation after stroke, robot-assisted training increases the chance of regaining independent walking ability, especially in more severely impaired patients, seems to be safe and increases muscle strength and quality of life in small trials., Conclusion: Early mobilization improves the outcome of the critically ill. Robotic devices support the gait training after stroke and are the subject of ongoing studies on early mobilization and verticalization in the intensive care setting., (© 2022. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

At the time of admission to an intensive or intermediate care unit, assessment of the patients' nutritional status may have both prognostic and therapeutic relevance with regard to the planning of individualized medical nutrition therapy (MNT). MNT has definitely no priority in the initial treatment of a critically ill patient, but is often also neglected during the course of the disease. Especially with prolonged length of stay, there is an increasing risk of malnutrition with considerable prognostic macro- and/or micronutrient deficit. So far, there are no structured, evidence-based recommendations for assessing nutritional status in intensive or intermediate care patients. This position paper of the Section Metabolism and Nutrition of the German Interdisciplinary Association for Intensive and Emergency Medicine (DIVI) presents consensus-based recommendations for the assessment and technical monitoring of nutritional status of patients in intensive and intermediate care units. These recommendations supplement the current S2k guideline "Clinical Nutrition in Intensive Care Medicine" of the German Society for Nutritional Medicine (DGEM) and the DIVI., (© 2022. The Author(s).)

Intensive Care Unit patients frequently develop physical impairments, mainly weakness, during their ICU stay. Early mobilization is a central therapeutic element in patients on an intensive care unit to prevent and treat these physical sequelae to conserve independence. Different barriers such as lacking patient motivation, insufficient staffing and fear of dislocating vascular access or the airway led to insufficient implementation of current guideline recommendation. Integration of modern medical equipment as well as the adequate ICU room concepts is a promising option to overcome those barriers.Allowing for sufficient free floor area when planning an ICU - maybe through the integration of mobile elements - is likely to ease early mobilization and should be thoroughly considered when building or remodeling an ICU. Furthermore, wireless monitoring has been deemed necessary and could potentially decrease the fear regarding dislocation due to less cable or lines that need to be managed during mobilization.Virtual reality is a rapidly evolving field and while in ICU patients it could so far only show to reduce stress level it has been shown to improve rehabilitation in stroke patients. It is imaginable that its integration in mobilization on the ICU will boost patients' motivation. Trials are still outstanding.Robotics integrated in the ICU bed or in form of exoskeletons are currently being piloted in critically ill patients with many expected benefits due to the ability to support patients tailored to their individual needs, reduce staff requirements as the robotics will cover support function and improved duration and intensity of mobilization as for example the patient can be ambulated without ever leaving the bed, which also translates into potentially reduced fear regarding dislocation of the airway or vascular access.Currently, evidence on the benefits regarding the integration of ICU rooms as well as modern medical technology into the process of (early) mobilization is lacking but especially in the sector of robotics a huge potential is to be suspected., Competing Interests: Erklärung zu finanziellen Interessen Forschungsförderung erhalten: ja, von einer anderen Institution (Pharma- oder Medizintechnikfirma usw.).; Honorar/geldwerten Vorteil für Referententätigkeit erhalten: ja, von einer anderen Institution (Pharma- oder Medizintechnikfirma usw.).; Bezahlter Berater/interner Schulungsreferent/Gehaltsempfänger: ja, von einer anderen Institution (Pharma- oder Medizintechnikfirma usw.); Patent/Geschäftsanteile/Aktien (Autor/Partner, Ehepartner, Kinder) an im Bereich der Medizin aktiven Firma: ja, von einer anderen Institution (Pharma- oder Medizintechnikfirma usw.); Patent/Geschäftsanteile/Aktien (Autor/Partner, Ehepartner, Kinder) an zu Sponsoren dieser Fortbildung bzw. durch die Fortbildung in ihren Geschäftsinteressen berührten Firma: nein. Erklärung zu nichtfinanziellen Interessen NEXT Chair – ESICMLenkungsausschuss TifoNet – DGAI, (Thieme. All rights reserved.)

Background: Early mobilization is defined as intervention within the first 72 h after intensive care unit (ICU) admission. According to the current state of relevant studies, evidence on early mobilization in critically ill patients is still inconsistent. This leads to insecurity in caretakers and subsequently to incomplete implementation in German ICUs., Objectives: What type of intervention is suitable for certain patient groups? Which issues remain unresolved?, Results: To obtain best possible outcomes, early mobilization should be initiated during the first 72 h after ICU admission. Implementation of early mobilization improves clinical outcome and should be integrated in a patient-centered bundle (such as ABCDEF). Mechanical ventilation is not a contraindication to intervention. Evidence in neurocritical care as well as functionally dependent patients is still low. Mode of intervention and dosage of early mobilisation remain unclear., Conclusion: Early mobilization is safe and feasible, resulting in improved outcomes in surgical and medical ICU patients. Further studies are necessary to evaluate the optimal dosage and duration of intervention, especially in neurocritical care patients.