Anasthesiologie Intensivmedizin Notfallmedizin Schmerztherapie最新文献

The Section Metabolism and Nutrition of the German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI) recently published two position papers specifying some aspects of the guideline on clinical nutrition for critically ill patients published by the German Society for Nutritional Medicine in 2018. This article provides a condensed overview for clinical practice; some key aspects of these position papers are presented focussing on the monitoring of energy expenditure and macronutrient administration.

Medical Nutrition Therapy (MNT) is a key component of treatment in intensive care units (ICU) and plays a crucial role in the prognosis of critically ill patients. An individualized nutrition strategy is essential to meet the specific needs of critically ill patients and to minimize potential complications.Recommendations for MNT differ between the guidelines of the German Society for Nutritional Medicine (DGEM), the European Society for Clinical Nutrition and Metabolism (ESPEN), and the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.), making its implementation in clinical practice challenging. Therefore, the first part of this article provides a pragmatic summary of the current recommendations for everyday clinical practice. The second part focuses on recent data and how these might influence current paradigms of MNT for critically ill patients, with particular emphasis on phase-appropriate macronutrient delivery and combinations of nutrition with other interventions.

The market offers a wide range of medical nutrition formulations for oral, enteral and parenteral nutrition of critically ill patients. In addition to so-called "standard" nutrition formulations, which are available in different variants and already cover a wide range of products, there are also specialized nutrition formulations that have been developed specifically for certain diseases.According to current evidence, normocaloric "standard" nutrition formulations are the first choice. However, in certain cases, depending on the clinical picture, phase of illness and individual tolerance, energy-dense or protein-rich variants as well as fiber-containing or fiber-free options may also be useful. These products enable individualized disease- and phase-specific nutrition therapy in clinical practice.However, the evidence for the benefits of specialized nutrition formulations that are tailored to specific metabolic changes and particular needs of individual clinical pictures is currently limited. Such specialized products should therefore only be used in individual cases and under consideration of medical and therapeutic conditions: Special nutrition formulations for patients with diabetes mellitus and kidney disease can simplify metabolic control and the practice of nutritional therapy. By carrying out close metabolic monitoring, special nutrition formulations can be used individually in these patients. However, specialized nutrition formulations for patients with liver or lung disease are not recommended based on current evidence and guidelines.While the evidence for the use of special substrates in pharmacological doses is still limited, they are an integral part of clinical nutrition products in physiological doses.Particular attention should be paid to complete protein/amino acid patterns (dispensable, indispensable and conditionally indispensable amino acids) and mixed lipid emulsions (soy, olive, fish oil, medium-chain triglycerides) in parenteral nutrition products.

The use of ultrasound in regional anaesthesia is increasingly establishing itself as the gold standard, as supported by the 2021 PERSEUS guideline on the perioperative use of ultrasound in regional anaesthesia. This guideline reviews the effectiveness, safety, and training requirements for ultrasound-guided anaesthesia techniques and provides recommendations for various block techniques as well as educational approaches for sonography-based methods. Studies show that the use of ultrasound generally increases success rates and reduces complications, particularly in performing upper and lower extremity blocks. However, there remains significant heterogeneity in the data, and clear recommendations are still lacking for many techniques, especially for truncal and neuraxial blocks. The guideline specifies quality indicators, though the data supporting these is occasionally unclear. For training and education, a structured model combining practical and theoretical knowledge is recommended. The authors of the guideline regard ultrasound as the standard in regional anaesthesia due to its visual safety advantages, although the application for some procedures is not yet fully evidence-based.

In addition to antibiotic stewardship, infection prevention and control (IPC) measures at the hospital are crucial for containing antimicrobial resistance (AMR). Nosocomial infections can be prevented through the consistent application of recommended IPC measures. This reduces the use of antibiotics and therefore the development of AMR. In this way, antibiotic stewardship and IPC go hand in hand.

Breast cancer ranges among the most commonly diagnosed oncological diseases worldwide. Strategies of timely detection and advanced multimodal therapies have significantly improved 10-year survival rates. Hence, breast cancer survivors regularly present for non-cancer related procedures. This challenges the historical practice of complete avoidance of ipsilateral venous catheter placement or blood pressure measurements. While this dogma has evolved from the belief these interventions might increase the risk of breast-cancer related lymphedema, a growing body of evidence has now proven otherwise. Ipsilateral venipunctures and catheters are not associated with increased complications of transitional limb swelling or persistent edema and ipsilateral procedures are therefore not contraindicated. Education of patients and providers are necessary to clarify on this long-standing myth.

The increasing prevalence of multidrug-resistant organisms (MDRO) poses a major threat to healthcare systems. Critically ill patients are at heightened risk to acquire MDRO infections resulting in longer hospital stays and higher mortality rates. This article provides an overview of preventive measures, divided into Infection Prevention and Control (IPC) and Antimicrobial Stewardship (AMS) approaches. IPC measures focus on the prevention of MDRO spread by applying basic and extended hygiene strategies. While basic hygiene such as hand and surface disinfection are effective in stopping any pathogen transmission, extended hygiene strategies including screening approaches, patient isolation and contact precautions are essential to identify MDRO patients and separate them from other susceptible patients. On the one hand, AMS aims at reducing the development of resistances under selective pressure by rational use of antimicrobials. On the other hand, interdisciplinary AMS-teams provide recommendations to optimize targeted MDRO therapy, including the rational use of "new" antibiotics. By pursuing different starting points, both IPC- and AMS-strategies are necessary in the prevention of MDRO development and transmission.

Antibiotic stewardship (ABS) in intensive care units is confronted with challenges that go beyond a rational assessment of the use of anti-infective substances. Regular analyses of anti-infective prescribing are an essential element of ABS and help to identify areas of ABS activity. Even after 10 years of continuous ABS supervision of an intensive care unit, the need for personnel and time remains high. However, the introduction of an electronically managed patient file makes it significantly easier to prepare and perform ward rounds with focus on ABS. The interdisciplinary discussion at the patient's bedside facilitates the recognition of both intensive care as well as infectious and pharmaceutical aspects of anti-infective therapy evolving in a therapeutic consensus. This requires in-depth clinical experience for all ABS team members. Clinically experienced ward pharmacists can improve communication within the treatment team by being available as an on-site contact person for compatibilities, therapeutic drug monitoring, etc. during a pharmaceutical ward round.