Medizinische Klinik-Intensivmedizin Und Notfallmedizin最新文献

Background: Low cardiac output syndrome (LCOS) following coronary artery bypass grafting (CABG) remains a major cause of morbidity and mortality. Standard inotropes frequently provide only marginal hemodynamic benefit and are associated with increased myocardial oxygen consumption and arrhythmogenic risk. Levosimendan, a calcium sensitizer with inodilatory properties, may offer more favorable hemodynamics without these adverse effects.

Methods: In this retrospective study, we evaluated 41 patients with LCOS post-CABG who failed to respond to standard catecholamines, defined by < 20% improvement in cardiac output. Levosimendan (0.1-0.2 µg/kg/min over 24 h) was administered. Hemodynamic parameters including cardiac index (CI), systemic vascular resistance (SVR), mean arterial pressure (MAP), cardiac power index (CPi), and serum lactate were recorded at baseline and at 3, 24, 48, 72, and 96 h post-infusion.

Results: Levosimendan significantly increased CI from 2.08 ± 0.08 to 2.89 ± 0.19 L/min/m² at 48 h (p = 0.003) and CPi from 0.32 ± 0.01 to 0.50 ± 0.01 W/m² (p = 0.002). Serum lactate declined from 5.5 ± 0.8 to 2.45 ± 0.4 mmol/L (p = 0.01). SVR decreased from 1334 ± 108 to 1079 ± 73 dyn·s·cm⁻⁵ (p = 0.09). In contrast, initial norepinephrine/epinephrine/dobutamine therapy resulted in a minor CI increase (2.08 ± 0.08 to 2.15 ± 0.08 L/min/m²; p = 0.05) and no significant improvement in MAP or lactate. With levosimendan no tachycardia or persistent hypotension was observed; catecholamine requirements declined over 72 h.

Conclusion: This retrospective single-center case series suggests that levosimendan may be associated with hemodynamic improvement in patients with LCOS after CABG who are unresponsive to standard therapy. However, due to the absence of a control group and the retrospective design, these findings should be considered exploratory and hypothesis-generating.

Background: A complication of stroke is the pusher syndrome (PS). PS results in an altered verticality perception and in a reduced clinical outcome. Effective interventions in the treatment of PS, feasible in nursing care, are lacking to date.

Aim: Examining whether neurophysiological massage has effects on the perception of verticality (primary outcome) and whether effects on the severity of PS can be proved (secondary outcome).

Method: Participants of this multicentered, randomized controlled trial will be recruited in the setting of acute and rehabilitation hospitals. The participants of the intervention group will receive once a day, on eight consecutive days a neurophysiological massage, while the control group will receive usual care including training for selfcare and clothing skills as well as mobilization into the wheelchair. The primary outcome will be evaluated in the sitting position, immediately after conducting the intervention, after 10 minutes, and 3 days after the intervention period ends by measuring the shank deviation angle compared to the body midline. The secondary outcome will be evaluated before starting and after ending the intervention period as well as 3 days after the intervention period ends by using the scale of contraversive pushing (SCP). Furthermore, problem-centered interviews will be conducted pre- and post-interventionally and analyzed using the Witzel method.

Expected results: The hypothesis of whether neurophysiological massage could improve the perception of verticality in patients affected by PS more than usual care will be examined. The study could show an effect of neurophysiological massage on the perception of the subjective postural vertical. Conducting interviews will allow a holistic understanding of PS.

Background: The long-term sequelae of intensive care treatment are summarized as postintensive care syndrome (PICS), which affects physical, cognitive and psychological health and can also impact children (PICS-p) and families (PICS-F).

Objective: Due to the heterogeneous long-term sequelae, an interdisciplinary treatment approach is necessary; however, current healthcare structures in the German-speaking region are not designed for transitional care, including a coordinated outpatient follow-up or care following neurological rehabilitation. The aim of this work is to identify challenges in PICS outpatient diagnostics, treatment and organization and to develop suggestions for improving care.

Material and methods: The Postintensive Care Syndrome Section of the German Interdisciplinary Association of Critical Care and Emergency Medicine (DIVI) provides an overview of the current challenges and addresses them from a healthcare perspective.

Results: Care for PICS patients in German-speaking countries is severely limited due to the absence of ICD-10 codes and billing possibilities, a small number of specialized university outpatient clinics, and insufficient outpatient follow-up care. In particular, the period following rehabilitation is marked by a lack of adequate follow-up care and limited awareness within the outpatient sector.

Conclusion: Future efforts should focus on raising awareness among healthcare professionals about this complex syndrome and establishing a continuous interdisciplinary care pathway from intensive care units to rehabilitation and PICS outpatient clinics. Additionally, the introduction of ICD coding and the creation of reimbursable care structures are necessary.

In cases of severe pneumonia, prone positioning therapy has been shown to have a positive effect in patients receiving invasive mechanical ventilation. In addition, during the COVID-19 pandemic, a positive effect was demonstrated in patients who did not yet require mechanical ventilation (endotracheal intubation) and who received prone positioning therapy before these measures were taken (awake prone positoning). Currently, the influence of awake prone positioning therapy in patients without COVID-19 has not been sufficiently investigated. This recommendation aims to explain the indications, side effects, contraindications, and implementation of awake prone positioning in conscious critically ill patients.

After successful resuscitation, cases of persisting neurological deficits or prolonged intensive care usually require inpatient neurological rehabilitation treatment. Depending on the severity this is either early neurological and neurosurgical rehabilitation in phase B as a continuation of acute hospital treatment or neurological rehabilitation in phase C or D. To relieve the burden on intensive care and monitoring wards in acute care hospitals, phase B often initially involves intensive care with weaning from ventilation and decannulation. In this phase, quantitative and qualitative disturbances of consciousness often occur, along with disorientation and behavioral disorders in the sense of organic psychosis or delirium. After reorientation and sufficient independence in activities of daily living, rehabilitation with a focus on the remaining individual neurological and neuropsychological deficits is then possible, which can individually be very different. This requires regular monitoring of progress and adjustment of therapy goals. Residual emotional, memory or cognitive problems after discharge from inpatient rehabilitation can often prevent return to work and can pose major challenges to home life.

Background: In Germany, the alternative care of patients with ambulatory treatment needs has been discussed for years as a way to relieve emergency departments. This study provides insights into currently implemented models of patient streaming and integrated acute and emergency care.

Methods: Between July 2023 and July 2024 emergency department physicians were surveyed online. One section targeted management personnel and gathered information on care structures and case numbers. Based on this, the potential for relieving emergency departments was calculated. The analysis was descriptive.

Results: Of the 370 participants 28% (n = 105) held management positions in the emergency department and 50% (n = 45) of those with alternative structures reported collaborations with the Association of Statutory Health Insurance Physicians. Standardized patient streaming was implemented in 43% (n = 24), often based on triage. The median indicated relief potential was 21%.

Discussion: The findings reveal a heterogeneous care landscape with varying patient streaming approaches and relevant potential to relieve emergency departments. Due to the small number of cases and a convenience sample, the results should be interpreted as exploratory. Further research could support the evidence-based development of acute and emergency care.