Medizinische Klinik-Intensivmedizin Und Notfallmedizin最新文献

Objective: The explicit prohibition of discontinuing intensive care unit (ICU) treatment that has already begun by the newly established German Triage Act in favor of new patients with better prognoses (tertiary triage) under crisis conditions may prevent saving as many patients as possible and therefore may violate the international well-accepted premise of undertaking the "best for the most" patients. During the COVID-19 pandemic, authorities set up lockdown measures and infection-prevention strategies to avoid an overburdened health-care system. In cases of situational overload of ICU resources, when transporting options are exhausted, the question of a tertiary triage of patients arises.

Methods: We provide data-driven analyses of score- and non-score-based tertiary triage policies using simulation and real-world electronic health record data in a COVID-19 setting. Ten different triage policies, for example, based on the Simplified Acute Physiology Score (SAPS II), are compared based on the resulting mortality in the ICU and inferential statistics.

Results: Our study shows that score-based tertiary triage policies outperform non-score-based tertiary triage policies including compliance with the German Triage Act. Based on our simulation model, a SAPS II score-based tertiary triage policy reduces mortality in the ICU by up to 18 percentage points. The longer the queue of critical care patients waiting for ICU treatment and the larger the maximum number of patients subject to tertiary triage, the greater the effect on the reduction of mortality in the ICU.

Conclusion: A SAPS II score-based tertiary triage policy was superior in our simulation model. Random allocation or "first come, first served" policies yield the lowest survival rates, as will adherence to the new German Triage Act. An interdisciplinary discussion including an ethical and legal perspective is important for the social interpretation of our data-driven results.

Background: Abnormal thyroid markers are a frequent occurrence in emergency and intensive care medicine. Correct interpretation of their clinical relevance and distinction from a primary thyroid disease, particularly prior to potential administration of iodine-containing antiarrhythmic drugs such as amiodaron or radiocontrast agents, are both essential and challenging.

Objective: This article aims to present the pathophysiology of abnormal thyroid markers in acute or protracted critical disease. Their relevance for administration of amiodaron or iodine-containing radiocontrast agents is discussed, and concrete practical recommendations are presented.

Materials and methods: The current work comprises a discussion of expert recommendations, guidelines, and basic research.

Results and conclusion: Approximately one third of intensive care patients develop non-thyroidal illness syndrome (NTIS) during the course of their critical disease. NTIS is characterized by a reduction in the serum concentration of fT3 and, during the course, also in those of thyroid-stimulating hormone (TSH) and fT₄, despite an organically intact thyroid gland. A greater extent of the deviations correlates with a worse overall prognosis. The mechanisms involved are manifold and influence different levels of hormonal signaling axes. They are mediated by interaction with acute stress signals such as inflammatory factors and elevated cortisol levels and are influenced by medication. The components vary depending on disease severity and the protracted course. NTIS does not require any specific treatment; the focus is on treating the underlying disease. Latent hyperthyroidism in particular must be distinguished from NTIS. In unclear situations and high-risk constellations, perchlorate is indicated before (and after) iodine exposure.

Background: In 2019 the World Health Organization (WHO) listed antimicrobial resistance among the top 10 threats to global health. The Seraph® 100 Microbind® Affinity blood filter (Seraph® 100) has been in use since 2019 to eliminate pathogens from the bloodstream in addition to anti-infective pharmacotherapy. It is the first device used to rapidly and efficiently reduce the number of circulating bacteria and viruses.

Objective: After a background on the concept of extracorporeal pathogen removal in general, this review summarizes the preclinical and clinical data on the Seraph® 100 Affinity Blood Filter. The clinical effect of this treatment and potential therapeutic options are described.

Methods: Structured PubMed review including references published up to February 2024.

Results: Case reports, uncontrolled observational studies and data from registries show widespread clinical use of the Seraph® 100 ranging from difficult to treat bacterial (super) infections to viral infections. The treatment can be done as stand-alone hemoperfusion or in combination with all forms of kidney replacement therapy as well as in extracorporeal membrane oxygenation.

Conclusion: The use of the Seraph® 100 varies in terms of duration, concomitant therapy and clinical settings. Due to the absence of prospective controlled trials the clinical effect cannot be properly evaluated.

The therapeutic target of extracorporeal carbon dioxide removal (ECCO₂R) is the elimination of carbon dioxide (CO₂) from the blood across a gas exchange membrane without influencing oxygenation to a clinically relevant extent. In acute respiratory distress syndrome (ARDS), ECCO₂R has been used to reduce tidal volume, plateau pressure, and driving pressure ("ultraprotective ventilation"). Despite achieving these goals, no benefits in outcome could be shown. Thus, in ARDS, the use of ECCO₂R to achieve ultraprotective ventilation can no longer be recommended. Furthermore, ECCO₂R has also been used to avoid intubation or facilitate weaning in obstructive lung failure as well as to avoid mechanical ventilation in patients during bridging to lung transplantation. Although these goals can be achieved in many patients, the effects on outcome still remain unclear due to lack of evidence. Despite involving less blood flow, smaller cannulas, and smaller gas exchange membranes compared with extracorporeal membrane oxygenation, ECCO₂R bears a comparable risk of complications, especially bleeding. Trials to define indications and analyze the risk-benefit balance are needed prior to implementation of ECCO₂R as a standard therapy. Consequently, until then, ECCO₂R should be used in clinical studies and experienced centers only. This article is freely available.

Extracorporeal cardiopulmonary resuscitation (ECPR) describes the use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) to restore blood circulation in patients during refractory cardiac arrest. So far, ECPR is not the standard of care but has become part of clinical routine for select patients in many places. As ECPR is a highly invasive support option associated with considerable risks for fatal complications, premature use in patients who may have return of spontaneous circulation should be avoided. However, the selection criteria for ECPR are still evolving, as the search for evidence is ongoing. Recent randomized controlled trials of different ECPR strategies support its use within integrated systems built around highly specialized ECPR centers. The ECPR caseload is an important predictor of patient survival, and continuous training is key for evidence-based quality of care. Typical complications after ECPR include vascular injury or malposition of cannulas, thrombotic complications, hemolysis, and bleeding events that require early detection and interdisciplinary management. When provided by highly specialized and well-trained expert teams in dedicated ECPR centers within integrated pre-hospital and intra-hospital emergency care systems, ECPR may improve survival in select patients with refractory cardiac arrest. This article is freely available.

Anticoagulation is an essential component of optimal extracorporeal membrane oxygenation (ECMO) management. Unfractionated heparin is still the anticoagulant of choice in most centers due to longstanding familiarity with the agent. Disadvantages include alterations in drug responses due to its capability to bind multiple heparin-binding proteins that compete with antithrombin and the potential for heparin-induced thrombocytopenia. In such cases, direct thrombin inhibitors are the treatment of choice but pose difficulties in monitoring due to the limited experience and target ranges for non-aPTT-guided management (aPTT: activated partial thromboplastin time). The current trend toward low-dose anticoagulation, especially for venovenous ECMO, is supported by data associating bleeding complications with mortality but not thromboembolic events, which include circuit thrombosis. However, only prospective data will provide appropriate answers to how to individualize anticoagulation, transfusions, and bleeding management which is currently only supported by expert opinion. Empiric therapy for ECMO patients based on laboratory coagulation alone should always be critically questioned. In summary, only collaboration and future studies of coagulation management during ECMO will help us to make this life-saving therapy that has become part of daily life of the intensivist even safer and more effective. Until then, a fundamental understanding of coagulation and bleeding management, as well as pearls and pitfalls of monitoring, is essential to optimize anticoagulation during ECMO. This article is freely available.

Background: The use of extracorporeal membrane oxygenation (ECMO) for patients with acute respiratory distress syndrome (ARDS) has increased substantially. With modern trials supporting its efficacy, ECMO has become an important tool in the management of severe ARDS.

Objectives: The objectives of this paper are to discuss ECMO physiology and configurations used for patients with ARDS, review evidence supporting the use of ECMO for ARDS, and discuss aspects of management during ECMO.

Conclusion: Current evidence supports the use of ECMO, combined with an ultra-lung-protective approach to mechanical ventilation, in patients with ARDS who have refractory hypoxemia or hypercapnia with severe respiratory acidosis. Furthermore, data suggest that center volume and experience are important factors in the care of patients receiving ECMO. The use of extracorporeal technologies in expanded patient populations and the optimal management of patients during ECMO remain areas of investigation. This article is freely available.

Mortality in infarct-related as well as heart failure-associated cardiogenic shock remains high, reaching 40-50% depending on the etiology and severity of cardiogenic shock. Percutaneous active mechanical circulatory support devices including veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and microaxial left ventricular mechanical circulatory support devices are rapidly evolving in their use. However, evidence of VA-ECMO therapy has only recently emerged and showed no benefit for mortality, with an associated higher complication rate. Evidence for microaxial left ventricular mechanical circulatory support devices such as the Impella pump (Abiomed, Danvers/MA, USA) is limited. The current article aims to give an overview of the basics of VA-ECMO therapy and microaxial left ventricular mechanical circulatory support devices, the current evidence, ongoing trials, patient selection, and potential complications. This article is freely available.

Background: Direct oral anticoagulants (DOAC) are increasingly used for prophylaxis and treatment of thromboembolic events. Incorrectly dosed DOAC treatment is associated with excess mortality.

Purpose: This article aims at raising awareness of DOAC overdosing and its causes as well as presenting a diagnostic and therapeutic work-up.

Material and methods: Based on a case presentation, a structured review of the current literature on DOAC overdosing was performed and treatment recommendations were extracted.

Results: In addition to wittingly or unwittingly increased DOAC intake, common causes of overdose are inadequate dose adjustment for concomitant medication or comorbidities. Global coagulation testing should be supplemented with DOAC-specific testing. Severe bleeding and the need for invasive diagnostics or urgent surgery represent indications for treating DOAC overdoses. Based on the cause of an DOAC overdose, active charcoal, endoscopic pill rescue, antagonization with idarucizumab or andexanet alfa and the targeted substitution of coagulation factors represent treatment options.

Conclusion: The sensitization of clinicians is important to ensure a timely diagnosis and adequate treatment of DOAC overdosing. This report provides an overview of current knowledge on diagnostics and treatment; however, further studies are necessary to improve the existing algorithms.