Medizinische Klinik-Intensivmedizin Und Notfallmedizin最新文献

Background: Postextubation dysphagia (PED) represents a significant morbidity and mortality factor even in nonneurological intensive care units (ICU), potentially prolonging both ICU and overall hospital stays.

Methods: A literature review was conducted to access the relevance, diagnostic approaches, and therapeutic options for PED, which were then placed in context using a clinical case study.

Results: Although evidence-based guidelines for PED are lacking in the literature, several articles and recommendations addressing multiprofessional treatment strategies were identified. In addition to the necessity of systematic dysphagia screening and early therapeutic interventions, particular attention should be paid to predictors that can be identified early-for example, through the use of checklists-and addressed by a multiprofessional care team.

Conclusion: Interdisciplinary collaboration is essential for the effective diagnosis and management of PED with the potential to improve both clinical outcomes and quality of life in affected patients. In particular, early screening, daily activation of orofacial functions within nursing care, targeted swallowing therapy, mobilization, respiratory therapy and device-supported respiratory therapy may contribute to improved patient trajectories following extubation.

Background: The number of long-term ventilated patients in out-of-hospital intensive care (OIC) in Germany has risen sharply in recent years. Due to financial disincentives, structural care deficits and resource bottlenecks, there is an increasing risk of inadequate care. In 2020, the Intensive Care and Rehabilitation Strengthening Act (IPReG) was therefore passed by legislators with the aim of improving OIC. This study examines the opportunities and challenges of the IPReG with regard to the care of long-term ventilated patients in OIC from the perspective of payers and healthcare policy.

Materials and methods: A qualitative interview study was conducted as part of the process evaluation of the multicenter study PRiVENT (Prevention of invasive Ventilation). Using semi-structured, guideline-based individual interviews, health policy actors and representatives of statutory health insurers were asked about the IPReG.

Results: In all, 11 health policymakers and 12 representatives of statutory health insurance companies took part in the interviews. Both interview groups showed a positive attitude towards the IPReG and expressed the expectation of added value for the outpatient care of long-term ventilated patients. The current remuneration regulations for weaning and the assessment of weaning potential in the OIC were criticized, among other things.

Conclusion: The IPReG provides a legal basis for improving OIC, but there is still room for improvement in its current version. The evaluation planned by legislators should be used to identify potential weaknesses and make appropriate adjustments.

Postcardiac arrest syndrome is characterized by the following: 1) hypoxic-ischemic brain injury, 2) postresuscitation myocardial dysfunction, 3) systemic ischemia/reperfusion injury, and 4) the persistent precipitating pathology. Pathophysiologically, no flow during cardiac arrest leads to global ischemia of all tissues, which already initiates early inflammatory processes. Subsequently, reperfusion (during cardiopulmonary resuscitation and after return of spontaneous circulation) triggers a complex cascade of events, including systemic inflammation, endothelial activation and procoagulant processes and-in the presence of oxygen-the formation of tissue-damaging reactive oxygen species. Taken together this may cause microcirculatory disturbances and myocardial dysfunction leading to shock and hypoperfusion and ultimately to organ failure. Furthermore, disruption of the blood-brain barrier and cerebral autoregulation cause ongoing neuronal death. Ultimately, the exaggerated inflammation may lead to an immunoparalytic state, making survivors susceptible to severe (nosocomial) infections in the postresuscitation course.

Despite major advances, morbidity and mortality after cardiac arrest remain high. Postresuscitation care requires a multimodal, time-coordinated approach. The International Liaison Committee on Resuscitation (ILCOR) model describes four phases of brain injury, explaining the failure of single-target therapies. Cardiac arrest centers consolidate expertise and improve survival and neurological outcomes in observational studies, although randomized trials remain inconclusive. Hypoxia must be avoided, while hyperoxia should not be pursued; a MAP of 60-65 mm Hg is adequate. Immediate PCI is mandatory in STEMI but not without ST-elevation. ECPR may benefit selected patients if implemented early. Temperature management now focuses on fever prevention. Prognostication must be multimodal and appropriately timed to avoid premature withdrawal of life-sustaining therapy.

Acute abdomen can represent a serious clinical condition with a variety of different and potentially life-threatening underlying causes. Rapid identification of the underlying etiology through a structured approach and the prompt initiation of adequate diagnostic and treatment measures is highly relevant in order to reduce the patient's mortality risk. This article provides an overview of important differential diagnoses of an acute abdomen and describes recommended diagnostic and therapeutic measures that are relevant in acute and emergency clinical care.

The causes of out-of-hospital cardiac arrest (OHCA) are diverse and can broadly be divided into cardiac and noncardiac causes. Despite successful cardiopulmonary resuscitation (CPR), in-hospital mortality remains high and is influenced by multiple factors. In recent years, alongside the prevention of recurrent cardiac arrest, the development of targeted treatment strategies has increasingly come into focus. Recommendations for care within specialized structures exist but have not yet been implemented nationwide. In parallel, the German Resuscitation Council (GRC) reaffirmed its 2015 recommendation to treat OHCA patients in specialized and certified centers (Cardiac Arrest Centers, CAC). Against this background, an interdisciplinary care concept was established at the University Medical Center Freiburg, represented by the so-called Cardiac Arrest Receiving Team (CART). The aim is to provide OHCA patients with standardized pathways that ensure clear diagnostic and therapeutic strategies immediately after hospital admission. Core elements include the defined composition of the CART, explicit criteria for determining the primary place of care, and the implementation of structured, sequential workflows.

Following initially successful resuscitation and the achievement of a spontaneous rhythm, patients are mostly comatose and are transferred to the intensive care unit. The brain is particularly vulnerable for injuries under global ischemia or hypoxia and therefore severe brain damage without damage to other organs is a frequent occurrence. This is referred to as hypoxic-ischemic encephalopathy (HIE) and preferentially affects neurons in the cerebral cortex, the basal ganglia and the cerebellum. The brain stem is less vulnerable. The unresponsive wakefulness syndrome (UWS), previously known as apallic syndrome or vegetative state, is a frequent form of HIE and can persist for years in a ventilation nursing home. In many patients multimodal neurological prognostication enables a reliable prediction on whether a relevant recovery of cerebral function is likely or impossible, even during the stay in the intensive care unit. These include the clinical neurological examination after a sufficiently long observational time of mostly at least 72h, cerebral imaging, i.e., cranial computed tomography (cCT), if necessary cranial magnetic resonance imaging (cMRI), electrophysiological examinations (electroencephalography, EEG), median nerve somatosensory evoked potentials (SSEP) and determination of blood biomarkers (neuron-specific enolase, NSE, neurofilament light chains, NFL). Findings that make a severe HIE very likely are a bilateral lack of pupillary light reflex 72h after resuscitation, bilateral absence of cortical median nerve SSEP, highly malignant EEG pattern, NSE levels > 90 ng/ml and a lack of gray-white differentiation of the cerebrum in cCT. A normal NSE or NFL level 48-96h after resuscitation, an early continuous EEG with responses to external stimuli, high amplitudes of the median nerve SSEP and a normal cMRI make a severe HIE improbable. If the short-term clinical course and the prognostic investigations do not provide a clear determination of the extent of the HIE, a time-limited trial of a neurological early rehabilitation can clarify the question whether regaining consciousness with relevant cognitive functions occurs or not.