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Thrombotic microangiopathies (TMA) are rare diseases, which are defined by the triad microangiopathic hemolytic anemia, thrombocytopenia and organ damage, and are associated with high morbidity and mortality. The recognition of a TMA and the distinction of important differential diagnoses are key factors, particularly in a perioperative context and in routine clinical intensive care. The further differentiation of the different TMA subtypes, such as thrombotic thrombocytopenic purpura (TTP), Shiga toxin-producing Escherichia coli hemolytic uremic syndrome (STEC-HUS) and atypical hemolytic uremic syndrome (aHUS), based on the underlying pathophysiology and the development of new targeted treatment options in recent years have significantly improved the prognosis. A close interdisciplinary cooperation between critical care specialists and specialist disciplines experienced in the treatment of TMA, is essential for a prompt diagnosis and the initiation of the appropriate treatment. [ABSTRACT FROM AUTHOR]

The insertion of a gastric tube in the operating room (OR) or in an intensive care unit (ICU) is a routine procedure. Although the tube is often inserted by nursing staff, the indications and selection of the procedure for position control remain the physician's responsibility. For immediate position control, the injection of air through the inserted tube with simultaneous auscultation of the epigastrium is probably the most simple and common clinical method. A typical "bubbling" is often regarded as a sufficiently reliable sign of correct gastric tube position. This procedure can be described as a routine standard both in the OR and the ICU; however, numerous examples from clinical practice and quality reviews show gastric tube mispositioning in esophageal, bronchial, pulmonary or even pleural positions in individual cases. Since auscultation findings are misinterpreted as tracheal, bronchial, or pleural secretions, mispositioning may remain undetected. In addition, adequate documentation of the procedure is lacking. In the worst case, hyperosmolar tube feeding occurs via the malpositioned tube into the lungs or pleural space causing subsequent severe pneumonia or pleuritis, which is often fatal for the patient outcome. In contrast to many other similar procedures in intensive care medicine, such as the installation of central venous catheters or endotracheal intubation, to our knowledge there is no uniform standard for forensic verification of the correct position after gastric tube positioning. The present work provides an overview of existing practices and the scientific background for confirmation of gastric tube positioning without ionizing radiation. [ABSTRACT FROM AUTHOR]

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 1 0 i ndicators 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. [ABSTRACT FROM AUTHOR]

The consensus-based guideline "SARS-CoV-2, COVID-19 and (early) rehabilitation" for Germany has two sections: In the first part, the guideline addresses infection protection-related procedures during the COVID-19 pandemic. In the second part, it provides practice recommendations for rehabilitation after COVID-19. The specific recommendations for rehabilitation after COVID-19 as issued by 13 German medical societies and two patient-representative organizations are presented together with general background information for their development. [ABSTRACT FROM AUTHOR]

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The current S2k guidelines on the diagnostics and treatment of peripartum hemorrhage are summarized in this article from the perspective of anesthesiology based on a fictitious case report. The update of the guidelines was written under the auspices of the German Society of Gynecology and Obstetrics with the participation of other professional societies and interest groups from Germany, Austria and Switzerland and published by the AWMF in 2022 under the register number 015/063. [ABSTRACT FROM AUTHOR]

Modern intensive care medicine is caught between the conflicting demands of an efficient but also increasingly more technical intensive care treatment with numerous therapeutic options and, at the same time, an ageing society with increasing morbidity. This is reflected, among other things, in an increasing number of ventilated patients in intensive care units and an increasing proportion of patients for whom ventilation cannot easily be discontinued. Weaning from a ventilator, which can account for more than 50% of the total ventilation time, therefore plays a central role in this process. This main topic article presents the need for strategically wise and holistic actions to minimize the consequences of invasive mechanical ventilation for patients. An attempt is made to shed more light on individual aspects of the ventilation weaning process with high relevance for clinical practice. Especially for prolonged weaning from ventilation, many more concepts are needed than simply ending ventilation. [ABSTRACT FROM AUTHOR]

Background: Fast-track concepts have fundamentally changed the perioperative care of patients in the last 30 years. Sufficient evidence is available for these concepts. Objective: The aim of this article is to evaluate the dissemination of fast-track concepts in Germany based on routine data. Material and methods: A retrospective analysis of all colorectal resections performed at the Helios Clinics in 2016–2021 was carried out. These were analyzed with respect to the length of hospital stay, intensive care unit occupancy, ventilation proportion, mortality, complication rate and access approach. Results and discussion: A transfer to the intensive medical care unit is still the standard in Germany after colorectal resection. For oncological colorectal resection, in particular, two thirds of the patients are still perioperatively treated on the intensive care unit. The duration of inpatient hospital stay for colorectal resection is still excessively long in international comparisons and has also only diminished slowly in recent years (e.g. colon cancer 2016: 18.6 ± 11.9 days and 2021: 13.8 ± 9.3 days). The proportion of open surgical interventions is declining but still accounts for a relevant proportion even 30 years after the implementation of laparoscopy (e.g. colon cancer 2016: 71.10% and 2021: 56.44%). Therefore, the care of patients with colorectal resection still does not seem to be implemented according to the fast-track principle [ABSTRACT FROM AUTHOR]

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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. [ABSTRACT FROM AUTHOR]

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Copyright of Medizinische Klinik: Intensivmedizin & Notfallmedizin is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Circadian body and behavior rhythms serve to coordinate and maintain the physiological processes in the human body. A disruption of these rhythms frequently occurs in intensive care patients and can be the cause for the development of delirium. This review article discusses the underlying pathophysiological mechanisms and develops a chronobiologically oriented prevention and treatment approach for delirium in the context of intensive care medicine. [ABSTRACT FROM AUTHOR]

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Background: Intensive care unit-acquired weakness (ICU-AW) is one of the most frequent causes of neuromuscular dysfunction in intensive care medicine. To date no evidence-based recommendations exist for the diagnostics, monitoring or further intensive care treatment. Objective: To evaluate the current clinical practice of diagnostics, monitoring and treatment strategies of ICU-AW on intensive care units in Germany. Material and methods: We conducted an online survey with a self-designed questionnaire and invited 448 members of the Scientific Working Group for Intensive Care Medicine (WAKI) and the Scientific Working Group for Neuroanesthesia (WAKNA) to participate. Results: A total of 68/448 (15.2%) questionnaires were analyzed. Of the participants 13.4% (9/67) stated that a structured diagnostic approach for the detection of ICU-AW is applied in their units. The clinical examination was the preferred method for screening (60/68; 88.2%) and follow-up (57/65; 87.7%). Scores, such as the Medical Research Council sum score (MRC-SS) seem to be less important for the screening (7/68; 10.3%) and follow-up assessment (7/65; 10.8%). Mobilization with physiotherapy (45/68; 66.2%) is the most common strategy applied to treat ICU-AW. A lack of physiotherapists (64/68; 94.1%) and intensive care nurses (57/68; 83.8%) are the main deficits identified in the care of patients with ICU-AW. The majority of the study participants (62/68; 91.2%) would welcome evidence-based guidelines for diagnostics, monitoring and treatment approaches in ICU-AW. Discussion: To date comprehensive recommendations for diagnostics, monitoring, prevention and treatment of ICU-AW are still lacking in German intensive care units. The introduction of new diagnostic approaches could help to detect ICU-AW and therefore to initiate earlier preventive and treatment approaches. [ABSTRACT FROM AUTHOR]

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The current S2k guidelines on treatment of thermal injuries in adults are summarized in this article from the perspective of anesthesiology, emergency medicine and intensive care medicine. The guidelines were prepared under the auspices of the German Society for Burn Medicine with the participation of other professional societies and interest groups and were published last year in revised form by the AWMF. [ABSTRACT FROM AUTHOR]

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Copyright of Medizinische Klinik: Intensivmedizin & Notfallmedizin is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Medizinische Klinik: Intensivmedizin & Notfallmedizin is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Background: A pre-existing anticoagulation treatment and predisposing diseases for thromboembolic events represent common problems in patients with sepsis or septic shock; however, these conditions are not addressed in current national guidelines for sepsis and septic shock. One of the aims of this nationwide survey in Germany was therefore to determine how intensive care physicians deal with these problems.Methods: From October 2019 to May 2020, we conducted a nationwide survey among German medical directors of intensive care units (ICU) addressing anticoagulation and drug-based prophylaxis of venous thromboembolism (VTE) in patients with sepsis and sepsis-induced coagulopathy. One focus was the procedure for patients with a pre-existing anticoagulation treatment or a previously known heparin-induced thrombocytopenia (HIT) type 2 (acute symptomatic vs. dating back years).Results: In most of the participating ICUs pre-existing anticoagulation is largely continued with low molecular weight heparin preparations or unfractionated heparin. In patients with pre-existing HIT type 2 both acute symptomatic and dating back years, argatroban represents the drug of choice. There is a high degree of variability in the definition of the target values, usually being well above the range for pure VTE prophylaxis.Conclusion: Data on the continuation of anticoagulation beyond VTE prophylaxis with a subsequently increased risk of bleeding in patients with sepsis and septic shock is limited and treatment decisions are in many cases subject to individual consideration by the practitioner. The results of our survey imply the need for a systematic work-up of this topic in order to support daily practice in many ICUs with the required evidence. [ABSTRACT FROM AUTHOR]

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Copyright of Medizinische Klinik: Intensivmedizin & Notfallmedizin is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

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The European guidelines on cardiopulmonary resuscitation, which are divided into 12 chapters, have recently been published. In addition to the already known chapters, the topics "epidemiology" and "life-saving systems" have been integrated for the first time. For each chapter five practical key statements were formulated. In the present article the revised recommendations on basic measures and advanced resuscitation measures in adults as well as on postresuscitation treatment are summarized and commented on. [ABSTRACT FROM AUTHOR]

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Background: The COVID-19 pandemic posed enormous challenges to the German healthcare system and highlighted the need for strategies to recruit, train, and deploy medical personnel. Until now, no holistic concept existed to use medical students as support for professionals in intensive care units (ICU) to avoid staff shortages in medical care.Method: In a large-scale pilot project 265 medical students were trained for an ICU assignment. The innovative training module was accompanied by a pre-post questionnaire for self-assessment of the skills learned. 22 weeks after the training module and still during the pandemic deployment, another questionnaire was used to evaluate experiences in deployment and the efficiency of the training module with respect to preparation for ICU deployment.Results: The analysis revealed significant mean differences for all COVID-19-specific variables (safety dimension) in favor of the training module (n = 168). The deployment evaluation showed that the training concept was inconsistently assessed as preparation for the work deployment for 69 of the 89 deployed students in total (53% agreement/47% disagreement).Conclusion: The results show a good feasibility of an innovative training concept for medical students with respect to a pandemic deployment as assistants in intensive care units. The concept is suitable for providing additional helpers in intensive care units during a pandemic; however, the inconsistent evaluation indicates that the concept can be expanded and needs to be adapted. [ABSTRACT FROM AUTHOR]

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The current outbreak of coronavirus disease (COVID-19) has reached Germany. The majority of people infected present with mild disease, but there are severe cases that need intensive care. Unlike other acute infectious diseases progressing to sepsis, the severe courses of COVID19 seemingly show prolonged progression from onset of first symptoms to life-threatening deterioration of (primarily) lung function. Diagnosis relies on PCR using specimens from the respiratory tract. Severe ARDS reflects the hallmark of a critical course of the disease. Preventing nosocomial infections (primarily by correct use of personal protective equipment) and maintenance of hospitals' operational capability are of utmost importance. Departments of Anaesthesia, Intensive Care and emergency medicine will envisage major challenges. [ABSTRACT FROM AUTHOR]

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Als eine Reaktion des deutschen Gesundheitssystems auf die Corona-Pandemie haben auch Kinderkliniken bzw. kinderchirurgische Abteilungen wie in der „Erwachsenenchirurgie“ elektive Operationen abgesagt und dringende Operationen priorisiert. Damit sollten zusätzliches Personal für die Betreuung von Intensivpatientinnen und -patienten freigestellt und zusätzliche intensivmedizinische Kapazitäten geschaffen werden. Für eine Situationsbeschreibung ist auf die wichtige, 2020 veröffentlichte gemeinsame Stellungnahme der Deutschen Gesellschaft für Kinderchirurgie (DGKCH), der Deutschen Gesellschaft für Kinder- und Jugendmedizin (DGKJ) und der Deutschen Gesellschaft für pädiatrische Infektiologie (DGPI) zum „Management kinderchirurgischer Patienten in der Covid-19-Pandemie“ hinzuweisen.

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Copyright of Anaesthesiologie & Intensivmedizin is the property of DGAI e.V. - Deutsche Gesellschaft fur Anasthesiologie und Intensivmedizin e.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Background: The COVID-19 pandemic challenges hospital clinicians by additional burdens. Key questions are whether hospital clinicians have experienced more stress in the care of COVID-19 patients and whether patient safety and quality of care have changed.Methods: Cross-sectional study using an online survey with clinicians in German hospitals on working conditions and quality of care during the COVID-19 pandemic, comparing clinicians with (MmK) vs. without direct contact (MoK) to COVID-19 patients.Results: In total, 2122 clinicians participated. Most clinicians were physicians (15.4%, n = 301) or nurses (77.0%, n = 1505) working in major acute care hospitals (46.0%, n = 899). Every second respondent stated that they worked more than usual (46.4%, n = 907) and took on additional activities (47.7%, n = 932). A quarter of the participants did not receive any training or get instructions in devices (21.5%, n = 421). Only 51.5% (n = 1006) of the respondents were provided with sufficient personal protective equipment. More than 30% (32.7%, n = 639) were more satisfied than usual. The comparing clinicans with vs. without direkt contact to Covid-19 patients worked more shifts than usual (> 2 shifts: 24.1%, n = 306 vs. 13.7%, n = 63, p < 0.001) and without instruction (27.9%, n = 364 vs. 17.1%), n = 57, p < 0.001). In terms of patient safety, there were more deficiencies in the care, mechanical ventilation and nursing (all p < 0.001).Conclusion: The cross-sectional study indicates an increased burden on clinicians and a restricted quality of care for patients with COVID-19. A risk to patients or clinicians cannot be excluded. [ABSTRACT FROM AUTHOR]

The treatment of patients with COVID-19 is a big challenge for intensive care units: substantial additional staff and material is needed to treat the surge of patients admitted in short time. Treatment is difficult as many patients present with multiple organ failure, including acute respiratory distress syndrome (ARDS). Mostly, oxygenation is substantially impaired and compliance low, and many patients need prone positioning. This article deals with the difficulties during the first surge of patients with COVID-19. The suffering of the relatives who were not allowed to visit must also be considered. [ABSTRACT FROM AUTHOR]

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Background: The infraclavicular puncture of the subclavian vein is a standard procedure for anesthetists. Meanwhile the literature and recommendations are clear and the use of real-time ultrasound guidance is the standard procedure; however, anesthetists will always get into special circumstances were they have to use the landmark technique, so this competence must be preserved. Feared complications of infraclavicular subclavian vein puncture are pneumothorax and arterial puncture. Up to now there is no clear learning curve for the infraclavicular subclavian vein puncture in the landmark technique performed by anesthetists.Objective: The aim of this study was to examine the influence of the puncture experience on the success rate and mechanical complications, such as pneumothorax and arterial puncture in patients who received an infraclavicular subclavian vein puncture with the landmark technique. Three levels of experience were defined for comparison: inexperienced 0-20 punctures, moderately experienced 21-50 and experienced over 50 punctures.Material and Methods: Post hoc analysis of a previously published noninferiority study to examine the influence of ventilation on the pneumothorax rate in the subclavian vein puncture using the landmark technique. This analysis included 1021 anesthetized patients who were included in the original study between August 2014 and October 2017. Demographic data as well as the number of puncture attempts, puncture success, the overall rate of mechanical complications, pneumothorax rate and arterial puncture rates were calculated.Results: The overall rate of mechanical complications (pneumothorax + arterial puncture) was significantly higher in the inexperienced group (0-21) compared to the experienced group (>50, 15% vs. 8.5%, respectively, p = 0.023). This resulted in an odds ratio of 0.52 (confidence interval, CI: 0.32-0.85, p = 0.027). Likewise, the rate of puncture attempts in the group of inexperienced (0-20) with 1.85 ± 1.12 was significantly higher than in the group of experienced (>50, 1.58 ± 0.99, p = 0.004) and resulted in an odds ratio of 0.59 (CI: 0.31-0.96, p = 0.028). Although the puncture attempts of the moderately experienced (21-50) compared to the inexperienced (0-20) was not significant lower, we found an odds ratio of 0.69 (CI: 0.48-0.99, p = 0.042). The rate of successful puncture was 95.1% in the experienced group versus 89.3% in the inexperienced group (p = 0.001), which resulted in an odds ratio of 2.35 (CI: 1.28-4.31, p = 0.018). When viewed individually, no significant differences were found for pneumothorax and arterial puncture.Conclusion: In this post hoc analysis of the puncture of the subclavian vein using the landmark technique, we found a significant reduction of puncture attempts and overall mechanical complications. At least 50 punctures seem to be necessary to achieve the end of the learning curve; however, the landmark technique should only be used under special circumstances, when real-time ultrasound is not available. Anesthetists who want to complete their repertoire and learn the landmark technique should always perform a static ultrasound examination before starting the puncture in order to reduce complications due to anatomical variations or thrombosis. [ABSTRACT FROM AUTHOR]