Medizinische Klinik-Intensivmedizin Und Notfallmedizin最新文献

Background: In this study, we aimed to evaluate the role of the glucose-to-potassium ratio in predicting in-hospital mortality and prognosis of patients diagnosed with sepsis and septic shock in an emergency department and admitted to an emergency critical intensive care unit (ICU).

Methods: This study was a retrospective and observational evaluation of nontraumatic sepsis and septic shock patients > 18 years of age who were admitted to the emergency department of a tertiary training and research hospital and had available glucose and potassium values at the time of admission. The patients were evaluated over a 24-month period. The primary goal of this study was to examine the relationship between the glucose-to-potassium ratio and in-hospital mortality in sepsis patients.

Results: Data derived from 175 patients were included in the statistical analysis. Blood urea nitrogen, creatinine, lactate dehydrogenase, direct bilirubin, C‑reactive protein, and lactate levels were found to be significantly higher in the nonsurvivor group than in the survivor group (p < 0.05). On the other hand, hemoglobin, hematocrit, albumin, pH, HCO₃ and base excess levels were found to be statistically significantly higher in the survivor group than in the nonsurvivor group (p < 0.05). The glucose-to-potassium ratio was not significant in terms of predicting mortality in sepsis patients (p = 0.324). In the receiver-operating characteristic (ROC) analysis of various parameters' significance in terms of predicting mortality, APACHE 2 scores had the highest area under the curve (AUC) value (0.729).

Conclusion: According to the results of this study, the glucose-to-potassium ratio did not have a significant value in predicting mortality risk in sepsis and septic shock patients admitted from the emergency department to the emergency critical ICU.

Background: Pulmonary arterial embolism (PE) is not well characterized in elderly patients. In addition, unnecessary computed tomography pulmonary angiography (CTPA) examinations are often performed within this patient group, especially if the pretest probability is low.

Objective: To identify differences in clinical presentation in patients aged ≥80 years compared to patients <80 years and the effect of a BGA-optimized pretest probability to reduce unnecessary CTPAs according to age category.

Materials and methods: A retrospective analysis of patients with suspected PE and subsequent CTPA was performed, with evaluation of clinical data including capillary blood gas analysis (BGA) parameters (including standardized partial pressure of oxygen [sPaO₂]) over a 5-year period. Subsequently, the clinical characteristics of patients with confirmed PE were compared between the two age groups. In addition, an age-adjusted analysis of a BGA-optimized algorithm was performed in patients with a low pretest probability (PTP) according to the Wells score to reduce unnecessary CTPAs.

Results: PE was confirmed in 433 of 1538 patients with suspected PE, of which n = 98 (22.6%) were ≥ 80 years of age. Elderly patients with PE were less frequently male (p < 0.001), had lower rates of tachycardia (p = 0.021), but higher rates of cardiovascular disease history (p = 0.001) and oxygen administration at admission (p = 0.006) compared to those < 80 years. Signs of right heart dysfunction (p = 0.047) and elevated cardiac biomarkers (troponin: p < 0.001; nt-pro-BNP: p = 0.026) were also more common in the elderly. Additionally, simplified Pulmonary Embolism Severity Index (sPESI, p < 0.001) and in-hospital or 30-day death risk (p < 0.001) were higher in the elderly. Using a BGA-optimized algorithm with sPaO₂, unnecessary CTPA examinations were reduced by 33.2% in younger patients (75 of 226 without PE) and 23.5% in elderly patients (8 of 34 without PE).

Conclusions: Elderly patients with PE are characterized by higher clinical risk markers and elevated mortality rates compared to younger patients. In patients with suspected PE but low PTP, however, a significant number of unnecessary CTPAs could be avoided by using an BGA-optimized pretest algorithm in elderly patients.

Background: Early mobilization of critical ill patients in the intensive care unit (ICU) has a positive effect on outcome. Currently, due to concerns of cerebral vasospasm and rebleeding patients with subarachnoid hemorrhage (SAH) have a prolong bedrest for 12-14 days.

Objective: What effect does early mobilization have on vasospasm, clinical outcome, length of stay and ICU complication rate in patients with SAH compared to standard treatment?

Methods: A systematic literature search was conducted in MEDLINE via the PubMed® (U.S. National Library of Medicine®, Bethesda, MD, USA) and CINAHL® (EBSCO, Ipswich, MA, USA) databases.

Results: A total of 14 studies were identified. Overall, the studies showed an improved functional outcome and a reduction in the length of hospitalization and ventilation time. Only in one study did vasospasms occur more frequently and the outcome of patients with early mobilization was worse.

Conclusion: Further research is needed to identify possible positive effects of early mobilization in patients with SAH and to be able to describe the risk-benefit ratio more precisely.

Intravenous thrombolysis (IVT) and endovascular therapy (EVT) are the cornerstones of acute ischemic stroke treatment. While IVT has been an integral part of acute therapy since the mid-1990s, EVT has evolved as one of the most effective treatments in medicine over the past decade. Traditionally, systemic thrombolysis has been performed with alteplase (rtPA). More recently, tenecteplase (TNK) has been shown to be non-inferior to rtPA. TNK has some pharmacological advantages over rtPA and may lead to earlier recanalization, particularly in large vessel occlusions. All recanalization therapies are highly time dependent. To ensure rapid treatment, standard operating procedures (SOPs) should be established and followed in clinical practice. The optimal time window for IVT is 4.5 h after symptom onset and can be extended up to 9 h using specialized imaging techniques. For EVT, studies suggest a time window up to 24 h after symptom onset. In some cases, EVT has been successfully performed beyond this time window. To select patients for EVT, advanced imaging identifying salvageable brain tissue might be necessary. Even in large ischemic stroke, EVT can still improve outcome. Compared to EVT, IVT requires fewer technical and human resources, so more stroke patients can potentially be treated. In contrast, EVT requires highly trained personnel with sophisticated equipment and can, therefore, only be performed in specialized centers. Both procedures should be combined within the 4.5 h time window for patients without contraindications.

Acute respiratory distress syndrome (ARDS) is defined as an acute inflammatory syndrome leading to increased pulmonary capillary leakage and subsequent interstitial and alveolar pulmonary edema. Hypoxia is the predominant symptom. The definition of ARDS comprises acute onset, bilateral patchy infiltration on chest X‑ray and a reduction of the ratio of arterial partial pressure of oxygen (PaO₂) to the fraction of inspired oxygen (FiO₂), which also determines the classification into mild (≤ 300), moderate (≤ 200) and severe (≤ 100) ARDS. Treating the underlying cause is the only causal treatment measure. The aim of adjunctive therapy is the maintenance of life or organ functions by ensuring an adequate gas exchange without further damaging the lungs. Adjunctive therapy consists mainly of individually adapted "protective" ventilation treatment and the prone position. In severest ARDS, the use of venovenous extracorporeal membrane oxygenation (VV-ECMO) can improve survival if strict criteria for indications and contraindications are followed.

Background: Strokes are common neurological emergencies that require rapid diagnosis to minimize long-term damage. Prehospital detection and triage play a critical role in patient outcomes.

Objective: How effective are different prehospital diagnostic tools for stroke detection, and which triage strategies optimize patient care?

Methods: The article compares prehospital diagnostic tools for stroke detection and evaluates different transport strategies. Case studies illustrate their practical application.

Results: Traditional stroke diagnosis methods have limitations, particularly in identifying strokes in the posterior circulation. Newer diagnostic tools that incorporate additional symptoms, such as dizziness and vision problems, show higher sensitivity. The choice of triage strategy depends on the severity of symptoms and regional factors. Direct transport to specialized centers is beneficial for severe strokes, while initial stabilization at nearby units is more efficient in rural areas.

Conclusion: Modern diagnostic tools offer better sensitivity for prehospital stroke detection. Regional cooperation and the selection of appropriate triage strategies are key to improving stroke care.

Background: CAR-T cell (chimeric antigen receptor T) therapy is now part of standard of care treatment of B‑cell lineage malignancies. Although it is an effective treatment, it comes along with adverse side effects and toxicities that may require intensive care therapy. The costs related to critical care therapy in critically ill patients after CAR‑T administration have not been evaluated.

Patients and methods: Retrospective analysis of all patients who had received CAR‑T therapy and were admitted to the intensive care unit (ICU) of a tertiary care university medical centre in Germany between 1 January 2019 and 31 December 2022. Cause of admission and ICU therapy as well as treatment and total hospitals costs were evaluated.

Results: Thirty patients with a history of CAR-T cell therapy for underlying haematological malignancy were included. The median age of all patients was 60 years (interquartile range [IQR] 50-70) and 37% (n = 11) were female. 93% (n = 28) of patients had non-Hodgkin lymphoma and 7% (n = 2) had multiple myeloma. The cohort was stratified whether the ICU admission was CAR‑T therapy related (i.e. within 30 days after CAR‑T therapy; 73%, n = 22) or the admission was of an other cause (> 30 days after CAR‑T therapy) (27%, n = 8). The median duration from CAR‑T therapy to ICU admission was 6 (range 5-8) days in CAR-T cell therapy associated ICU admissions compared with 52 (range 31-126) days in other admissions. The overall illness severity on admission was numerically higher in CAR-T-related ICU admission compared to other admissions (46 vs. 43 points, p = 0.18). Vasopressor therapy (50% vs. 75%; p = 0.19), invasive mechanical ventilation (27% vs. 50%; p = 0.24) and renal replacement therapy (14% vs. 50%; p < 0.05) were used in CAR-T-associated admission compared to other admissions, respectively. The ICU mortality (23% vs. 50%; p = 0.15) was higher in patients with other ICU admission. Median total costs of the entire inpatient stay in hospital were € 27,845 (range 8661-368,286 €) in CAR-T-associated ICU admissions compared to € 59,234 (range 23,182-127,044 €) in the group of other ICU admissions (costs of the CAR‑T product not included).

Conclusion: In relation to the total costs of CAR-T-cell therapy (production of the CAR‑T product), therapy-associated complications have a relatively low impact on the costs and utilization of ICU resources.