Medizinische Klinik-Intensivmedizin Und Notfallmedizin最新文献

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.

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.

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.

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.