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Background: The 11th revision of the International Classification of Diseases (ICD-11) will come into effect in January 2022. Among other things, The Third International Consensus Definitions for Sepsis and Septic Shock (SEPSIS‑3 definition) will be implemented in it. This defines sepsis as a "life-threatening organ dysfunction caused by a dysregulated host response to infection". The aim of the present secondary analysis of a survey on the topic of "sepsis-induced coagulopathy" was to evaluate whether the SEPSIS‑3 definition, 4 years after its international introduction, has arrived in everyday clinical practice of intensive care units (ICU) run by anesthesiologists in Germany and thus the requirements for its use of the ICD-11 are given.

Methods: Between October 2019 and May 2020, we carried out a nationwide survey among German medical directors of ICUs. In a separate block of questions we asked about the definition of sepsis used in daily practice. In addition, we asked whether the quick-sequential (sepsis-related) organ failure assessment (qSOFA) score is used in screening for sepsis in the hospital to which to the participating ICU belongs.

Results: A total of 50 medical directors from anesthesiological ICUs took part in the survey. In total, the ICUs evaluated stated that they had around 14% of the high-care beds registered in Germany. The SEPSIS‑3 definition is integrated into everyday clinical practice at 78.9% of the university hospitals and 84.0% of the participating teaching hospitals. In contrast, the qSOFA screening test is only used by 26.3% of the participating university hospitals, but at least 52% of the teaching hospitals and 80% of the other hospitals.

Conclusion: The data show that both SEPSIS‑3 and qSOFA have become part of everyday clinical practice in German hospitals. The cautious use of qSOFA at university hospitals with simultaneous broad acceptance of the SEPSIS‑3 definition can be interpreted as an indication that the search for a suitable screening test for sepsis has not yet been completed.

The prophylaxis and treatment of postoperative pain to enhance patient comfort has been a primary goal of anesthesiologists for the last decades; however, avoiding postoperative nausea and vomiting (PONV) is, from a patient's perspective, a highly relevant and equally important goal of anesthesia. Recent consensus-based guidelines suggest the assessment of risk factors including female gender, postoperative opioid administration, non-smoking status, a history of PONV or motion sickness, young patient age, longer duration of anesthesia, volatile anesthetics and the type of surgery and reducing the patient's baseline risk (e.g. through the use of regional anesthesia and administration of non-opioid analgesics as part of a multimodal approach). In general, a liberal PONV prophylaxis is encouraged for adult patients and children, which should also be administered when no risk assessment is made. The basis for every adult patient should be a standard prophylaxis with two antiemetics, such as dexamethasone in combination with a 5-HT₃ receptor antagonist. In patients at high risk, this should be supplemented by a third and potentially a fourth antiemetic prophylaxis with a different mechanism of action. A recently published comprehensive Cochrane meta-analysis comparing available antiemetic prophylaxes reported the highest effectiveness to prevent PONV for the NK₁ receptor antagonist aprepitant (relative risk, RR 0.26), followed by ramosetron (RR 0.44), granisetron (RR 0.45), dexamethasone (RR 0.51) and ondansetron (RR 0.55), thereby revising the dogma that every antiemetic is equally effective. Adverse events of antiemetics were generally rare and reported in less than half of the included studies, yielding a low quality of evidence for these end points. In general, combinations of different antiemetics were more effective than single prophylaxes. In children above 3 years of age, the same principles should be applied as in adults. For these patients, there is a high degree of evidence for the combination of dexamethasone and 5‑HT₃ receptor antagonists. When PONV occurs, the consensus guidelines suggest that antiemetics from a class different than given as prophylaxis should be administered. To decrease the incidence of PONV and increase the quality of care, the importance of the implementation of institutional-level guidelines and protocols as well as assessment of PONV prophylaxis and PONV incidence is highly recommended.

Background: In German emergency rescue services, inhalation treatment is routinely carried out by qualified health personnel. Standard operating procedures (SOP) for nebulization are neither uniform throughout Germany nor available in all federal states. Standardized recommendations with respect to which nebulizer type should be used are missing. The aerosol output as well as the drug deposition rates of jet and mesh nebulizers, however, differ considerably. Mesh devices can achieve a threefold higher lung deposition. Their use in emergency departments has also been shown to be associated with a better patient outcome when compared to jet nebulizers.

Objective: This survey was designed to evaluate the type of nebulizer used in the south German rescue services. Special attention was paid to the influence of existing SOP on the decision to perform nebulization during emergency treatment.

Material and methods: A total of 4800 emergency paramedics working in Baden-Württemberg, Bavaria and Rhineland-Palatinate received a questionnaire with a total of 17 questions on the implementation of drug nebulization in the daily practice.

Results: Despite the existence of more efficient nebulizer types, the jet nebulizer was by far the most frequently used nebulizer in the south German rescue services. The deposition rates of both the jet and mesh nebulizers were considerably overestimated by most respondents; however, 77.5% of all respondents could not give any information about the deposition rates of the mesh nebulizer. Only two thirds of all respondents carried out nebulization treatment on the basis of SOP. The implementation of SOP, however, was pivotal to the application of nebulization during emergencies. If SOP were in place,76.9% of the responders used aerosol treatment compared to 23.1% when there were none. The perceived safety when using nebulization during emergencies was also significantly higher (p = 0.013) when SOP were implemented.

Conclusion: The exclusive use of mesh nebulizers could standardize the treatment of emergency patients in the south German rescue services. The use of mesh devices might possibly improve patient outcomes, even if clinical studies are still lacking. Nebulizer treatment differs between the federal states. A comprehensive implementation of SOP for nebulization treatment might support this process and could increase the application frequency and the perceived safety of nebulization during emergencies. A better training of paramedic personnel could improve the knowledge of aerosols as a treatment option for emergency patients and help to classify the advantages and disadvantages of the different aerosol generators available.

Physicians in acute and emergency medicine are increasingly confronted by geriatric, multimorbid or oncology patients with advanced stages of disease. Lacking further information or specification about the patient's will may result in overtreatment. An increasing part of the German population has advance directives; however, there is still uncertainty among physicians when dealing with advance directives and health care proxies. Misinterpretation may entail civil and criminal consequences or may lead to a withdrawal of the license to practice. Advance directives for instance are not equivalent to a general waiving of treatment and therapy. Besides life support, terminal care and its legal aspects must also be considered in acute medicine.

We report on a 28-year-old female patient who had no history of diseases and who was brought to our intensive care unit in a comatose state by the ambulance service. The clinical picture corresponded to sepsis with a massively increased blood sugar concentration (> 2000 mg/dl) as well as a pronounced skin mycosis in the groin region of the very obese patient (body mass index [BMI]: 33.7 kg/m²) in the physical examination. The treatment of sepsis was initially supplemented by a calculated antifungal treatment. The blood culture diagnosis confirmed the presence of Candida albicans and Candida glabrata. Despite adequate anti-infective treatment, the patient developed a septic shock in the further course, so that the additional escalation of treatment was initiated by renal replacement therapy on the second day and venovenous extracorporeal membrane oxygenation because of an ARDS. Despite all of these measures and maximum intensive care treatment, the patient developed a progressive multiple organ failure. When the pupils became rigid to light, a cerebral computed tomography was carried out. This showed evidence of a severe cerebral edema without signs of cerebral bleeding. Multiple examinations of somatosensory evoked potentials and electroencephalograms showed signs of irreversible brain damage. In view of this poor prognosis the therapeutic measures were limited. The patient died on day 24 after admission to the intensive care unit. The case study shows that antifungal treatment should definitely be considered in the context of sepsis treatment if there is a clinically justified suspicion.The role of the severely altered metabolic situation with massive hyperglycemia and ketoacidosis cannot be finally assessed.

Background: A team in the operating room (OR) is a hierarchically structured, gender-mixed group of people belonging to different professional categories. Disparities in the objectives of the different team members under economic pressure to perform, are sources of potential conflict in the daily work routine. This may have a negative impact on patient safety and commercial efficiency of hospital management.

Objective: The aim of this summary is to sensitize the reader to the complex of problems in daily life in the OR and to increase awareness of possible approaches to solve the difficulties in an OR. Problem solutions might be approached by improvement of communication and team building.

Methods: Narrative review of current literature and expert recommendations by a literature search in PubMed and Medline; keywords included teamwork, communication, operating room, team building.

Results and conclusion: Communication and teamwork in the OR are of immense importance for patient safety and the economic development of a hospital. Improvements in communication structure, among other things due to the implementation of a team time out and moderation from outside (OR manager) offer solutions to avoid conflicts in everyday clinical practice.

In 1981 the Canadian Peter Stewart presented a new concept for the interpretation of the acid-base balance. Rehm et al. published the first German language article on this topic. In 2007 the works of Deetjen and Lichtwarck-Aschoff as well as Funk presented both the physiological and clinical foundations of the Stewart concept as well as algorithms to interpret the acid-base status more precisely. Furthermore, since 2004 many other publications on the Stewart concept have been published, which have sometimes been controversially discussed and has not yet found its way into the everyday interpretation of blood gas analysis. This gap is intended to be filled by this work. It introduces a simple, practical algorithm and provides an approach to understanding the acid-base balance and the Stewart concept, which assumes that the plasma ions determine the pH value and the base excess (BE) in the plasma.