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ZusammenfassungDie Lärmbelastung auf der Intensivstation ist ein allgegenwärtiges, erhebliches Problem für Patienten und Personal. Viele maßgebliche Lärmquellen sind mitverantwortlich für die häufigen Schlafstörungen der Patienten, die das Auftreten eines Delirs begünstigen. Der Beitrag fasst die aktuelle Evidenz zur Entstehung lärmassoziierter Auswirkungen zusammen und zeigt Optionen zur Lärmreduktion und Verbesserung der Therapie von Intensivpatienten auf.

Background: In a retrospective observational study, we investigated patients with severe acute respiratory distress syndrome (ARDS) undergoing veno-venous (VV) extracorporeal membrane oxygenation (ECMO) support with known pulmonary arterial hypertension (PAH) and/or right ventricular (RV) failure treated with iNO. Objective: We analysed clinical characteristics such as time on mechanical ventilation, weaning from VV ECMO, organ dysfunction, the iNO therapy in terms of indication, dosing and duration, the ability of iNO to lower PAH in responder and non-responder patients, the survival rate, in-hospital mortality and long-term survival. Results: Of the 657 patients identified with ECMO support, 292 under VV ECMO support were evaluated and n=55 patients with iNO were included. We found that in-hospital mortality and long-term survival were poor in patients with severe ARDS under VV ECMO support with persistent PAH and/or RV failure. A rescue therapy with the pulmonary vasodilator iNO showed that only one-third of the cohort responded to the therapy with a sufficient decrease of the mean PAP. Survival between iNO responder and non-responder showed a trend albeit data between the groups were not statistically significant. We did not find a higher rate of continuous renal replacement therapy as marker for acute renal failure when iNO concentrations were ≤ 20 ppm and when the treatment duration stayed ≤ 3 days. Conclusions: This retrospective observational study suggests that persistent PAH and/or RV failure is associated with worse clinical outcome in patients with severe ARDS and VV-ECMO support. Concomitant treatment with the pulmonary vasodilator iNO reduced PAH and/or reversed RV dysfunction in only one-third of the patient population (iNO responder patients) but did not alter the rate of acute kidney failure.

We report valence band photoelectron spectroscopy measurements of gas-phase and liquid-phase benzene as well as those of benzene dissolved in liquid ammonia, complemented by electronic structure calculations. The origins of the sizable gas-to-liquid-phase shifts in electron binding energies deduced from the benzene valence band spectral features are quantitatively characterized in terms of the Born-Haber solvation model. This model also allows to rationalize the observation of almost identical shifts in liquid ammonia and benzene despite the fact that the former solvent is polar while the latter is not. For neutral solutes like benzene, it is the electronic polarization response determined by the high frequency dielectric constant of the solvent, which is practically the same in the two liquids, that primarily determines the observed gas-to-liquid shifts.

Birch reduction is a time-proven way to hydrogenate aromatic hydrocarbons (such as benzene), which relies on the reducing power of electrons released from alkali metals into liquid ammonia. We have succeeded to characterize the key intermediates of the Birch reduction process - the solvated electron and dielectron and the benzene radical anion - using cyclic voltammetry and photoelectron spectroscopy, aided by electronic structure calculations. In this way, we not only quantify the electron binding energies of these species, which are decisive for the mechanism of the reaction but also use Birch reduction as a case study to directly connect the two seemingly unrelated experimental techniques., after revision

Background Inhaled nitric oxide (iNO) has not been sufficiently evaluated in adult patients with severe acute respiratory distress syndrome (ARDS) under venovenous extracorporeal membrane oxygenation (VV ECMO) support. Objectives This study aims to assess survival in patients with severe ARDS under VV ECMO with iNO. Methods Of the 657 patients under ECMO, 292 under VV ECMO were evaluated. Outcomes in the iNO group (n = 55) were compared with those of the propensity-matched (based on age, sex, height, and sequential organ failure assessment score at admission) control cohort (55 patients under VV ECMO without iNO). Median survival was analyzed using the Kaplan–Meier method, whereas the hazard ratio for in-hospital mortality with iNO use was analyzed using the proportional hazards model. Results Weaning failure from VV ECMO was higher in the iNO group (69.7% vs. 47.3%, p = 0.0033). Thirty percent of patients responded sufficiently to iNO, showing a lower pulmonary arterial pressure. Survival was lower in the iNO group compared with the control cohort (22 vs. 109 days, p = 0.0222). The length of stay in the intensive care unit (ICU) (23 vs. 33 days, p = 0.0186) and total hospital stay (27 vs. 35 days, p = 0.0085) were shorter with iNO use. Survival was lower and the risk of mortality (hazard ratio, 1.8; 95% CI 1.1–3.0, p = 0.027) was higher in patients with iNO administration. Conclusions Inhaled NO in patients under VV ECMO is a strong predictor of shorter median time of survival and in-house mortality.

During sepsis, an initial prothrombotic shift takes place, in which coagulatory acute-phase proteins are increased, while anticoagulatory factors and platelet count decrease. Further on, the fibrinolytic system becomes impaired, which contributes to disease severity. At a later stage in sepsis, coagulation factors may become depleted, and sepsis patients may shift into a hypo-coagulable state with an increased bleeding risk. During the pro-coagulatory shift, critically ill patients have an increased thrombosis risk that ranges from developing micro-thromboses that impair organ function to life-threatening thromboembolic events. Here, thrombin plays a key role in coagulation as well as in inflammation. For thromboprophylaxis, low molecular weight heparins (LMWH) and unfractionated heparins (UFHs) are recommended. Nevertheless, there are conditions such as heparin resistance or heparin-induced thrombocytopenia (HIT), wherein heparin becomes ineffective or even puts the patient at an increased prothrombotic risk. In these cases, argatroban, a direct thrombin inhibitor (DTI), might be a potential alternative anticoagulatory strategy. Yet, caution is advised with regard to dosing of argatroban especially in sepsis. Therefore, the starting dose of argatroban is recommended to be low and should be titrated to the targeted anticoagulation level and be closely monitored in the further course of treatment. The authors of this review recommend using DTIs such as argatroban as an alternative anticoagulant in critically ill patients suffering from sepsis or COVID-19 with suspected or confirmed HIT, HIT-like conditions, impaired fibrinolysis, in patients on extracorporeal circuits and patients with heparin resistance, when closely monitored.

We present chemical kinetics measurements of the luminol oxydation chemiluminescence reaction at the interface between two aqueous solutions, using liquid jet technology. Free-flowing iquid microjets are a relatively recent development that has found its way into a growing number of applications in spectroscopy and dynamics. A variant thereof, called flat-jet, is obtained when two cylindrical jets of a liquid are crossed, leading to a chain of planar leaf-shaped structures of the flowing liquid. We here show that in the first leaf of this chain the fluids do not exhibit turbulent mixing, providing a clean interface between the liquids from the impinging jets. We also show, using the example of the luminol chemiluminescence reaction, how this setup can be used to obtain kinetics information from friction-less flow and by circumventing the requirement for rapid mixing but by intentionally suppressing all turbulent mixing and instead relying on diffusion.

ZusammenfassungDas innerklinische Notfallmanagement ist ein zentraler Baustein für die Patientensicherheit im Krankenhaus. Durch Frühwarnsysteme und die Etablierung Medizinischer Einsatzteams (MET) können sich verschlechternde Patienten frühzeitig erkannt und vermeidbare Todesfälle verhindert werden. Dieser Beitrag stellt wesentliche Elemente eines modernen innerklinischen Notfallmanagements dar.

Extracorporeal membrane oxygenation (ECMO) in acute respiratory distress syndrome (ARDS) is used to achieve oxygenation and protect lung ventilation. Near infrared spectroscopy (NIRS) measures cerebral regional tissue oxygenation (rSO2) and may contribute to patient safety during interhospital transport under ECMO support. We evaluated 16 adult ARDS patients undergoing interhospital ECMO transport by measuring cerebral rSO2 before and after initiation of ECMO support and continuously during transport. To compare peripheral oxygen saturation (SpO2) measurement with rSO2, both parameters were analyzed. NIRS monitoring for initiation of ECMO and interhospital transport under ECMO support was feasible, and there was no significant difference in the percentage of achievable valid measurements over time between cerebral rSO2 (88.4% [95% confidence interval {CI}, 81.3-95.0%]) and standard SpO2 monitoring 91.7% (95% CI, 86.1-94.2%), p = 0.68. No change in cerebral rSO2 was observed before 77% (73.5-81%) (median [interquartile range {IQR}]) and after initiation of ECMO support 78% (75-81%), p = 0.2. NIRS for cerebral rSO2 measurement is feasible during ECMO initiation and interhospital transport. Achievement of valid measurements of cerebral rSO2 was not superior to SpO2. In distinct patients (e.g., shock), measurement of cerebral rSO2 may contribute to improvement of patient safety during interhospital ECMO transport.

Objective: To assess the incidence and significance of invasive fungal diseases (IFD) during veno-venous (VV) ECMO support for acute respiratory distress syndrome (ARDS). Methods: Retrospective analysis from January 2013 to April 2021 of all ECMO cases for ARDS at a German University Hospital. In patients with IFD (IFD patients), type of IFD, time of IFD, choice of antifungal agent, duration, and success of therapy were investigated. For comparison, patients without IFD (non-IFD patients) were selected by propensity score matching using treatment-independent variables (age, gender, height, weight, and the Sequential Organ Failure Assessment (SOFA) score at ICU admission). Demographics, hospital and ICU length of stay, duration of ECMO therapy, days on mechanical ventilation, prognostic scores (Charlson Comorbidity Index (CCI), Therapeutic Intervention Scoring System (TISS), and length of survival were assessed. Results: A total of 646 patients received ECMO, 368 patients received VV ECMO. The incidence of IFD on VV ECMO was 5.98%, with 5.43% for Candida bloodstream infections (CBSI) and 0.54% for invasive aspergillosis (IA). In IFD patients, in-hospital mortality was 81.8% versus 40.9% in non-IFD patients. The hazard ratio for death was 2.5 (CI 1.1–5.4; p: 0.023) with IFD. Conclusions: In patients on VV ECMO for ARDS, about one in 17 contracts an IFD, with a detrimental impact on prognosis. Further studies are needed to address challenges in the diagnosis and treatment of IFD in this population.

Background: Veno-venous (VV) extracorporeal membrane oxygenation (ECMO) is increasingly used to support patients with severe acute respiratory distress syndrome (ARDS). In case of additional cardio-circulatory failure, some experienced centers upgrade the VV-ECMO with an additional arterial backflow cannula (termed VVA-ECMO). Here we analyzed short- and long-term outcome together with potential predictors of mortality. Methods: Retrospective analysis of outcome in VV ECMO patients with ARDS that received VVA upgrade due to acute cardio-circulatory deterioration from 2008-2021 at three ECMO referral centers.Results: We identified 73 VVA ECMO patients that either required an upgrade from VV to VVA (n=53) or were directly triple cannulated (n=20), most commonly for concomitant right-sided heart failure. Median (Interquartile Range) age was 49 (28-57) years and SOFA score was 14 (12-17) at VVA ECMO upgrade. ECMO support was required over 12 (6-22) days and ICU length of stay was 32 (16-46) days. Overall ICU mortality was 48% and hospital mortality 51%. Two additional patients died after hospital discharge while the remaining patients survived up to two years (with six patients being lost to follow-up). A SOFA score > 14 at the day of VVA upgrade and higher lactate level were independent predictors of mortality in the multivariate regression analysis.Conclusions: In this analysis, the use of VVA ECMO in patients with initial ARDS and concomitant cardiocirculatory failure was associated with a hospital survival of about 50%, and most of these patients survived up to 2 years. A SOFA score >14 and elevated lactate levels at the day of VVA upgrade predict unfavorable outcome.

Noise pollution in the intensive care unit is not only an omnipresent but also a considerable problem, both for patients and healthcare staff. There are a number of significant sources of noise that are at least partially responsible for the frequent and serious sleep disorders of intensive care unit patients. This has a negative impact on the recovery of intensive care patients and favours the occurrence of delirium, which can be associated with increased overall mortality. This article provides a summary of the current evidence on the occurrence of noise-associated consequences and possible options for reducing noise exposure in the intensive care unit and offers perspectives for improving treatment of intensive care patients.Die Lärmbelastung auf der Intensivstation ist ein allgegenwärtiges, erhebliches Problem für Patienten und Personal. Viele maßgebliche Lärmquellen sind mitverantwortlich für die häufigen Schlafstörungen der Patienten, die das Auftreten eines Delirs begünstigen. Der Beitrag fasst die aktuelle Evidenz zur Entstehung lärmassoziierter Auswirkungen zusammen und zeigt Optionen zur Lärmreduktion und Verbesserung der Therapie von Intensivpatienten auf.

Purpose: The question of whether cancer patients with severe respiratory failure benefit from veno-venous extracorporeal membrane oxygenation (vv-ECMO) remains unanswered. We, therefore, analyzed clinical characteristics and outcomes of a large cohort of cancer patients treated with vv-ECMO with the aim to identify prognostic factors. Methods: 297 cancer patients from 19 German and Austrian hospitals who underwent vv-ECMO between 2009 and 2019 were retrospectively analyzed. A multivariable cox proportional hazards analysis for overall survival was performed. In addition, a propensity score-matched analysis and a latent class analysis were conducted. Results: Patients had a median age of 56 (IQR 44–65) years and 214 (72%) were males. 159 (54%) had a solid tumor and 138 (47%) a hematologic malignancy. The 60-day overall survival rate was 26.8% (95% CI 22.1–32.4%). Low platelet count (HR 0.997, 95% CI 0.996–0.999; p = 0.0001 per 1000 platelets/µl), elevated lactate levels (HR 1.048, 95% CI 1.012–1.084; p = 0.0077), and disease status (progressive disease [HR 1.871, 95% CI 1.081–3.238; p = 0.0253], newly diagnosed [HR 1.571, 95% CI 1.044–2.364; p = 0.0304]) were independent adverse prognostic factors for overall survival. A propensity score-matched analysis with patients who did not receive ECMO treatment showed no significant survival advantage for treatment with ECMO. Conclusion: The overall survival of cancer patients who require vv-ECMO is poor. This study shows that the value of vv-ECMO in cancer patients with respiratory failure is still unclear and further research is needed. The risk factors identified in the present analysis may help to better select patients who may benefit from vv-ECMO.

Zusammenfassung Fragestellung Für Deutschland liegen nur wenige Daten zum Gesundheitszustand und Langzeitüberleben nach außerklinischer Reanimation vor. Die vorliegende Studie untersucht den allgemeinen Gesundheitszustand und das neurologische Langzeitergebnis 2,5 bis 5 Jahre nach dem Reanimationsereignis sowie den Zusammenhang zwischen Behandlungsergebnis und präklinischen Patienten- und Behandlungsfaktoren. Methodik Alle über einen Zeitraum von 30 Monaten (2011–2013) durch den Rettungsdienst der Stadt Bonn durchgeführten Reanimationen wurden auf Grundlage der Notarzteinsatzprotokolle und des Deutschen Reanimationsregisters retrospektiv analysiert. Der allgemeine Gesundheitszustand wurde in Anlehnung an den SF-12 erfasst und das neurologische Langzeitergebnis kategorisiert (Cerebral Performance Category [CPC]). Die vorliegenden Daten wurden einer uni- und multivariaten logistischen Regressionsanalyse unterzogen. Ergebnis Von insgesamt 458 Patienten überlebten 17,9 % bis zur Krankenhausentlassung, 13,8 % mehr als 2,5 Jahre und 7,7 % bis zum Stichtag der Befragung. Von den noch lebenden Patienten hatten 85,3 % ein gutes neurologisches Ergebnis (CPC ≤ 2), welches durch ein geringeres Alter, einen beobachteten Kollaps, die Durchführung einer Defibrillation und das Ausbleiben einer Vasopressorgabe begünstigt wurde (multivariate Analyse). 74,2 % der Überlebenden beschrieben ihren Gesundheitszustand als gut. Interpretation Insgesamt überleben langfristig nur wenige Patienten einen außerklinischen Herz-Kreislauf-Stillstand. Die überlebenden Patienten beurteilen ihren Gesundheitszustand als gut und zeigen ein gutes neurologisches Ergebnis. Dabei hängt dieses Behandlungsergebnis von denselben Parametern wie der primäre Reanimationserfolg (Überleben bis Krankenhausaufnahme) ab. Die Etablierung klinischer Instrumente zur frühen Prognoseerstellung ist wünschenswert. Hierzu sind weitere Langzeituntersuchungen größerer Patientenkollektive mit Zugriff auf Routinedaten notwendig.

Objective: To assess the feasibility of extracorporeal membrane oxygenation (ECMO) or life support (ECLS) as last resort life support therapy in patients with acute pancreatitis and subsequent secondary acute respiratory distress syndrome (ARDS). Methods: Retrospective analysis from January 2013, to April 2020, of ECMO patients with pancreatitis-induced ARDS at a German University Hospital. Demographics, hospital and ICU length of stay, duration of ECMO therapy, days on mechanical ventilation, fluid balance, need for decompressive laparotomy, amount of blood products, prognostic scores (CCI (Charlson Comorbidity Index), SOFA (Sequential Organ Failure Assessment), RESP(Respiratory ECMO Survival Prediction), SAVE (Survival after Veno-Arterial ECMO)), and the total known length of survival were assessed. Results: A total of n = 495 patients underwent ECMO. Eight patients with acute pancreatitis received ECLS (seven veno-venous, one veno-arterial). Five (71%) required decompressive laparotomy as salvage therapy due to abdominal hypertension. Two patients with acute pancreatitis (25%) survived to hospital discharge. The overall median length of survival was 22 days. Survivors required less fluid in the first 72 h of ECMO support and showed lower values for all prognostic scores. Conclusion: ECLS can be performed as a rescue therapy in patients with pancreatitis and secondary ARDS, but nevertheless mortality remains still high. Thus, this last-resort therapy may be best suited for patients with fewer pre-existing comorbidities and no other organ failure.

Background Extracorporeal membrane oxygenation (ECMO) support in acute respiratory failure may be lifesaving, but bleeding and thromboembolic complications are common. The optimal anticoagulation strategy balancing these factors remains to be determined. This retrospective study compared two institutional anticoagulation management strategies focussing on oxygenator changes and both bleeding and thromboembolic events. Methods We conducted a retrospective observational cohort study between 04/2015 and 02/2020 in two ECMO referral centres in Germany in patients receiving veno-venous (VV)-ECMO support for acute respiratory failure for > 24 h. One centre routinely applied low-dose heparinization aiming for a partial thromboplastin time (PTT) of 35–40 s and the other routinely used a high-dose therapeutic heparinization strategy aiming for an activated clotting time (ACT) of 140–180 s. We assessed number of and time to ECMO oxygenator changes, 15-day freedom from oxygenator change, major bleeding events, thromboembolic events, 30-day ICU mortality, activated clotting time and partial thromboplastin time and administration of blood products. Primary outcome was the occurrence of oxygenator changes depending on heparinization strategy; main secondary outcomes were the occurrence of severe bleeding events and occurrence of thromboembolic events. The transfusion strategy was more liberal in the low-dose centre. Results Of 375 screened patients receiving VV-ECMO support, 218 were included in the analysis (117 high-dose group; 101 low-dose group). Disease severity measured by SAPS II score was 46 (IQR 36–57) versus 47 (IQR 37–55) and ECMO runtime was 8 (IQR 5–12) versus 11 (IQR 7–17) days (P = 0.003). There were 14 oxygenator changes in the high-dose group versus 48 in the low-dose group. Freedom from oxygenator change at 15 days was 73% versus 55% (adjusted HR 3.34 [95% confidence interval 1.2–9.4]; P = 0.023). Severe bleeding events occurred in 23 (19.7%) versus 14 (13.9%) patients (P = 0.256) and thromboembolic events occurred in 8 (6.8%) versus 19 (19%) patients (P = 0.007). Mortality at 30 days was 33.3% versus 30.7% (P = 0.11). Conclusions In this retrospective study, ECMO management with high-dose heparinization was associated with lower rates of oxygenator changes and thromboembolic events when compared to a low-dose heparinization strategy. Prospective, randomized trials are needed to determine the optimal anticoagulation strategy in patients receiving ECMO support.

Nature 595(7869), 673 - 676 (2021). doi:10.1038/s41586-021-03646-5, Insulating materials can in principle be made metallic by applying pressure. In the case of pure water, this is estimated1 to require a pressure of 48 megabar, which is beyond current experimental capabilities and may only exist in the interior of large planets or stars2,3,4. Indeed, recent estimates and experiments indicate that water at pressures accessible in the laboratory will at best be superionic with high protonic conductivity5, but not metallic with conductive electrons1. Here we show that a metallic water solution can be prepared by massive doping with electrons upon reacting water with alkali metals. Although analogous metallic solutions of liquid ammonia with high concentrations of solvated electrons have long been known and characterized6,7,8,9, the explosive interaction between alkali metals and water10,11 has so far only permitted the preparation of aqueous solutions with low, submetallic electron concentrations12,13,14. We found that the explosive behaviour of the water–alkali metal reaction can be suppressed by adsorbing water vapour at a low pressure of about 10$^{−4}$ millibar onto liquid sodium–potassium alloy drops ejected into a vacuum chamber. This set-up leads to the formation of a transient gold-coloured layer of a metallic water solution covering the metal alloy drops. The metallic character of this layer, doped with around 5 × 10$^{21}$ electrons per cubic centimetre, is confirmed using optical reflection and synchrotron X-ray photoelectron spectroscopies., Published by Nature Publ. Group, London [u.a.]

Introduction Sepsis is a major cause of preventable deaths in hospitals. This study aims to investigate if sepsis incidence and quality of care can be assessed using inpatient administrative health data (IAHD).Methods and analysis Design: Retrospective observational validation study using routine data to assess the diagnostic accuracy of sepsis coding in IAHD regarding sepsis diagnosis based on medical record review. Procedure: A stratified sample of 10 000 patients with an age ≥15 years treated in between 2015 and 2017 in 10 German hospitals is investigated. All available information of medical records is screened by trained physicians to identify true sepsis cases (‘gold standard’) both according to current (‘sepsis-1’) definitions and new (‘sepsis-3’) definitions. Data from medical records are linked to IAHD on patient level using a pseudonym. Analyses: Proportions of cases with sepsis according to sepsis-1 and sepsis-3 definitions are calculated and compared with estimates from coding of sepsis in IAHD. Predictive accuracy (sensitivity, specificity) of different coding abstraction strategies regarding the gold standard is estimated. Predictive accuracy of mortality risk factors obtained from IAHD regarding the respective risk factors obtained from medical records is calculated. An IAHD-based risk model for hospital mortality is compared with a record-based risk model regarding model-fit and predicted risk of death. Analyses adjust for sampling weights. The obtained estimates of sensitivity and specificity for sepsis coding in IAHD are used to estimate adjusted incidence proportions of sepsis based on German national IAHD.Ethics and dissemination The study has been approved by the ethics commission of the Jena University Hospital (No. 2018-1065-Daten). The results of the study will be discussed in an expert panel to write a memorandum on improving the utility of IAHD for epidemiological surveillance and quality management of sepsis care.Trial registration number DRKS00017775; Pre-results.

A versatile, temperature controlled apparatus is presented, which generates deeply cooled liquid microjets of condensed gases, expelling them via a small aperture into vacuum for use in photoelectron spectroscopy (PES). The functionality of the design is demonstrated by temperature- and concentration-dependent PES measurements of liquid ammonia and solutions of KI and NH4I in liquid ammonia. The experimental setup is not limited to the usage of liquid ammonia solutions solely.

Background Extra Corporeal Membrane Oxygenation (ECMO) has become an accepted treatment option for severely ill patients. Due to a limited availability of ECMO support therapy, patients must often be transported to a specialised centre before or after cannulation. According to the ELSO guidelines, an ECMO specialist should be present for such interventions. Here we describe the safety and efficacy of a reduced team approach involving one anaesthesiologist, experienced in specialised intensive care medicine, and a specialised critical care nurse. Methods This study is a 10 years retrospective, single institution analysis of all data collected between January 2007 and December 2016 from the medical records at the University Hospital Bonn, Germany. Results The Bonner mobile ECMO team was deployed in 170 cases for on-site evaluation for ECMO support therapy. 4 (2.4%) patients died prior to arrival or during the implementation of ECMO support. Of the remaining 166 patients, 126 were cannulated at the referring site, 40 were transported without ECMO. Of those, 21 were subsequently cannulated out our centre. 19 patients never received ECMO treatment. The primary indication for ECMO treatment was ARDS (159/166 patients). Veno-venous ECMO was initiated in 137, whilst 10 patients received veno-arterial ECMO treatment. Mean transportation time was 75 ± 36 min, and mean transport distance was 56 ± 57 km. In total, 26 complications were observed, three being directly transport-related. The overall survival was 55%. Conclusions Initiation of extracorporeal membrane oxygenation and subsequent transport can be safely and efficiently performed by a two-man team with good outcome. Electronic supplementary material The online version of this article (10.1186/s12871-019-0687-9) contains supplementary material, which is available to authorized users.

The structure of emergency care is a key element for patients' safety in hospital. Early warning scores and the implementation of medical emergency teams (MET) can help to detect deteriorating patients early and prevent unexpected deaths. This article summarizes essential elements of a modern emergency management in hospitals.Das innerklinische Notfallmanagement ist ein zentraler Baustein für die Patientensicherheit im Krankenhaus. Durch Frühwarnsysteme und die Etablierung Medizinischer Einsatzteams (MET) können sich verschlechternde Patienten frühzeitig erkannt und vermeidbare Todesfälle verhindert werden. Dieser Beitrag stellt wesentliche Elemente eines modernen innerklinischen Notfallmanagements dar.

Purpose Extracorporeal membrane oxygenation (ECMO) is increasingly used with various indications. The clinical course can be complicated by an abdominal compartment syndrome (ACS). A decompressive laparotomy (DL) can be an option. Materials and methods Between 2014 and 2016 175 patients underwent ECMO support. Indications, demographic data, comorbidities, morbidity, mortality and length of stay were analyzed. Results Indications for ECMO were acute respiratory distress syndrome (n = 65), postpericardiotomy syndrome (n = 37), myocardial infarction (n = 26), extracorporeal cardiopulmonary resuscitation (n = 11), and others (n = 36). ECMO support was performed as veno-venous (VV, n = 91) or veno-arterial (VA, n = 84). Eleven patients developed ACS (VV-ECMO: n = 4; VA-ECMO: n = 7) and underwent DL. Three patients survived to hospital discharge. Risk factors were age (57 vs. 60.5 years, P = 0.032), a Charlson comorbidity index >1 (CCI, P = 0.004), a Simplified Acute Physiology Score (SAPS II) ≥ 42 at admission to ICU (P = 0.013) and ≥44 at the beginning of ECMO support (P = 0.004). When an ACS/DL occurred, mortality did not differ (DL: n = 11; 73% vs. no DL: n = 164; 65%; P = 0.749). Multivarate analysis revealed CCI and SAPS as independent predictors for mortality. Conclusions Approximately 10% of patients undergoing VA-ECMO support developed an ACS. If DL is undertaken, SAPS II scores can be used as predictive factor for mortality.

ZusammenfassungIm Gegensatz zur präklinischen Notfallmedizin existieren in Deutschland bis heute keine vergleichbaren fest etablierten Strukturen oder gesetzliche Vorgaben zur Aufbau- und Ablauforganisation sowie Personalqualifikation und Ausstattung der innerklinischen Notfallversorgung. Bei perioperativen Patienten treten unerwartete Komplikationen auf Normalstation jedoch relativ häufig auf. Oft sind bereits Stunden vor einem möglichen kritischen Ereignis Warnzeichen für eine Verschlechterung zu erkennen, wobei diese zu oft unbemerkt bleiben und es im Verlauf zu vermeidbaren schwerwiegenden Komplikationen oder Herz-Kreislauf-Stillständen kommen kann. Zur Verbesserung der innerklinischen Versorgungsstruktur und zur Vermeidung von innerklinischen Herz-Kreislauf-Stillständen dient die Etablierung sog. medizinischer Einsatzteams (engl. medical emergency teams). Dieser werden im Sinne eines präventiven Therapieansatzes bei erkennbaren Abweichungen der Vitalparameter frühzeitig alarmiert. Durch diesen präventiven Therapieansatz können innerklinische Kreislaufstillstände und ungeplante Aufnahmen auf eine Intensivstation vermieden und die perioperative Patientensicherheit erhöht werden.

The eligibility criteria for applying extracorporeal cardiopulmonary resuscitation (ECPR) in patients with cardiac arrest are currently unclear. For those patients with hypothermic cardiac arrest, the European Resuscitation Council (ERC) Guidelines recommend considering ECPR only for patients with potassium We report the case of an urban unwitnessed out-of-hospital cardiac arrest patient found with her head immersed in water at a temperature of 23°C. The patient presented an unclear history and a dire combination of clinical and laboratory parameters (asystole, arterial blood gas: pH 6.8, potassium 8.3 mmol/L, lactate 16.0 mmol/L). Despite these poor prognostic indicators, ECPR was initiated after 95 minutes of CPR and the patient survived with a good neurological outcome.This case highlights the uncertainty in ECPR eligibility and prognostication, especially in those with hypothermia and water immersion for whom aggressive therapies may be warranted. Further data and improved strategies are required to delineate candidacy for this resource-intensive procedure better.

Background: Despite being still invasive and challenging, technical improvement has resulted in broader and more frequent application of extracorporeal membrane oxygenation (ECMO), to prevent hypoxemia and to reduce invasiveness of mechanical ventilation (MV). Heparin-coated ECMO-circuits are currently standard of care, in addition to heparin based anticoagulation (AC) regimen guided by activated clotting time (ACT) or activated partial thromboplastin time (aPTT). Despite these advances, a reliable prediction of hemorrhage is difficult and the risk of hemorrhagic complication remains unfortunately high. We hypothesized, that there are coagulation parameters that are indices for a higher risk of hemorrhage under veno-venous (VV)-ECMO therapy. Methods: Data from 36 patients with severe respiratory failure treated with VV-ECMO at a University Hospital intensive care unit (ICU) were analyzed retrospectively. Patients were separated into two groups based on severity of hemorrhagic complications and transfusion requirements. The following data were collected: demographics, hemodynamic data, coagulation samples, transfusion requirements, change of ECMO-circuit during treatment and adverse effects, including hemorrhage and thrombosis. Results: In this study 74 hemorrhagic events were observed, one third of which were severe. Patients suffering from severe hemorrhage had a lower survival rate on VV-ECMO (43% vs . 91%; P=0.002) and in ICU (36% vs . 86%; P=0.002). SAPS II, factor VII and X were different between mild and severe hemorrhage group. Conclusions: Severe hemorrhage under VV-ECMO is associated with higher mortality. Only factor VII and X differed between groups. Further clinical studies are required to determine the timing of initiation and targets for AC therapies during VV-ECMO.