Medizinische Klinik-Intensivmedizin Und Notfallmedizin最新文献

Besides mechanical ventilation, renal replacement therapy is the most frequently performed organ replacement therapy in intensive care medicine. However, there is a lack of consensus- and evidence-based recommendations for the implementation of renal replacement therapy according to the best current knowledge and evidence. This guideline describes the topics of starting a renal replacement therapy, modality (diffusion or convection, continuous or intermittent procedures), anticoagulation, adequate dose, and criteria for stopping renal replacement therapy. In addition, the current evidence on adequate anti-infective therapy is presented under the special features of acute kidney injury and renal replacement therapy.

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.

Introduction: Intraosseous access (IO) is a crucial, life-saving alternative vascular access in paediatric emergency medicine. In awake paediatric patients, the pain of drilling and flushing the marrow cavity are barriers to the use of the IO method or prompt the use of an intraosseous anaesthetic agent, which introduces the risk of dosing errors and drug toxicity. This study aims to identify the frequency of use of anaesthetic agents and analyse the time delay caused by their use.

Methods: Prospective surveillance study analysing all patients, aged > 28 days to 18 years, who received one or more IO attempt(s) in and out of the hospital setting in Germany from 1 July 2017 to 30 June 2019 via the reporting mechanism of the German Paediatric Surveillance Unit (GPSU).

Results: Our analysis identified 74 patients who received an IO attempt while awake. All patients were younger than 6 years old. Almost every third child (31.6%) was awake during IO use. In 18.9% of all awake patients, an intraosseous anaesthetic was used before the IO was drilled or the marrow cavity was flushed, introducing a significant time delay of approximately 3 min (p = 0.001) compared to IO attempts without intraosseous anaesthesia.

Conclusions: Intraosseous anaesthesia prolongs the establishment of working vascular access in an emergency and introduces the risk of drug toxicity. To prevent adverse events, particular emphasis must be placed on placement without intraosseous anaesthesia, and alternative pain management (intranasal) must be considered if necessary. Training courses and guidelines should reflect the advised current practice.

Background: Weaning elderly patients with chronic obstructive pulmonary disease (COPD) from mechanical ventilation is a complex and critical process. This study aims to assess the efficacy of ultrasound monitoring of diaphragm function combined with sequential muscle training in predicting and facilitating this weaning process.

Methods: In this randomized controlled trial, 100 elderly COPD patients on mechanical ventilation were divided into two groups: an intervention group receiving sequential muscle training and a control group with standard care. The training regimen targeted the diaphragm and accessory respiratory muscles. Diaphragmatic ultrasonography was performed on participants to measure the right diaphragm excursion (DE), contraction velocity, diaphragm thickening fraction (DTF), and respiratory rate (RR)/DTF.

Results: The intervention group demonstrated significant improvements in diaphragmatic function, with mean DE increasing to 2.40 ± 0.46 cm, CV to 1.99 ± 0.37 cm/s, DTF to 0.35 ± 0.05, and RR/DTF 61.0 ± 8.0, compared to the control group's DE of 2.06 ± 0.46 cm, CV of 1.54 ± 0.44 cm/s, DTF of 0.30 ± 0.06, and RR/DTF 55.7 ± 7.3. Notably, the weaning success rate was higher in the intervention group (58.33%) compared to the control group (43.75%).

Conclusion: Sequential muscle training, alongside standard care, significantly improves diaphragmatic function and increases weaning success rates in elderly COPD patients. These findings suggest that incorporating targeted respiratory muscle training into the care regimen could facilitate the weaning process, highlighting the potential for improving patient outcomes in critical care settings.

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.

Life in an intensive care unit (ICU) involves the successful use of life-sustaining treatment and patients dying. In intensive care medicine, allowing a patient to die often means discontinuing life-sustaining measures. Together with the severity of the illness, this has a significant impact on the course of the dying process. End of life treatment and support focus on alleviating symptoms. The interprofessional team's task in the ICU is to anticipate, plan and implement palliative measures. A family-centered approach to palliative care requires providing human resources for psychosocial support and spiritual care for those affected. Implementing internal recommendations for action improves the quality of care. Training in the necessary skills to support people at the end of life is an integral component of education and ongoing professional development. This training includes basic knowledge of palliative care as well as specific knowledge about terminating life-sustaining measures.