RESUMO
BACKGROUND: End-of-life care (EOLC) in the intensive care unit (ICU) is becoming increasingly more common but ethical standards are compromised by growing economic pressure. It was previously found that perception of non-beneficial treatment (NBT) was independently associated with the core burnout dimension of emotional exhaustion. It is unknown whether factors of the work environment also play a role in the context of EOLC. OBJECTIVE: Is the working environment associated with perception of NBT or clinician burnout? MATERIAL AND METHODS: Physicians and nursing personnel from 11 German ICUs who took part in an international, longitudinal prospective observational study on EOLC in 2015-2016 were surveyed using validated instruments. Risk factors were obtained by multivariate multilevel analysis. RESULTS: The participation rate was 49.8% of personnel working in the ICU at the time of the survey. Overall, 325 nursing personnel, 91 residents and 26 consulting physicians participated. Nurses perceived NBT more frequently than physicians. Predictors for the perception of NBT were profession, collaboration in the EOLC context, excessively high workload (each pâ¯≤ 0.001) and the numbers of weekend working days per month (pâ¯= 0.012). Protective factors against burnout included intensive care specialization (pâ¯= 0.001) and emotional support within the team (pâ¯≤ 0.001), while emotional exhaustion through contact with relatives at the end of life and a high workload were both increased (each pâ¯≤ 0.001). DISCUSSION: Using the example of EOLC, deficits in the work environment and stress factors were uncovered. Factors of the work environment are associated with perceived NBT. To reduce NBT and burnout, the quality of the work environment should be improved and intensive care specialization and emotional support within the team enhanced. Interprofessional decision-making among the ICU team and interprofessional collaboration should be improved by regular joint rounds and interprofessional case discussions. Mitigating stressful factors such as communication with relatives and high workload require allocation of respective resources.
Assuntos
Esgotamento Profissional/prevenção & controle , Assistência Terminal/psicologia , Adulto , Atitude do Pessoal de Saúde , Esgotamento Profissional/etiologia , Cuidados Críticos , Emoções , Feminino , Humanos , Unidades de Terapia Intensiva , Estudos Longitudinais , Masculino , Enfermeiras e Enfermeiros/psicologia , Médicos/psicologia , Estudos Prospectivos , Inquéritos e Questionários , Assistência Terminal/métodosRESUMO
Extracorporeal cardiopulmonary resuscitation (eCPR) may be considered as a rescue attempt for highly selected patients with refractory cardiac arrest and potentially reversible etiology. Currently there are no randomized, controlled studies on eCPR, and valid predictors of benefit and outcome which might guide the indication for eCPR are lacking. Currently selection criteria and procedures differ across hospitals and standardized algorithms are lacking. Based on expert opinion, the present consensus statement provides a proposal for a standardized treatment algorithm for eCPR.
Assuntos
Reanimação Cardiopulmonar/métodos , Parada Cardíaca/terapia , Algoritmos , Consenso , Oxigenação por Membrana Extracorpórea/métodos , HumanosRESUMO
Intensive care medicine is an important and integral part of internal medicine. Modern intensive care medicine permits survival of many patients with severe and life-threatening internal diseases in acute situations. Decisive for therapeutic success is often not the application of complicated and expensive medical technologies, but rather the rapid diagnosis and identification of core issues, with immediate and competent initiation of standard treatment regimens. An adequately staffed, well-organized interprofessional team is of central importance. With the application of standard therapies, it has been increasingly demonstrated that "less is more", and that personalized treatment concepts are better than aggressive strategies with higher therapeutic goals. In accordance with the Choosing wisely recommendations of the American societies for intensive care medicine, the extended board of the Deutsche Gesellschaft für Internistische Intensivmedizin und Notfallmedizin (DGIIN) has formulated five positive and five negative recommendations reflecting these principles. The current paper is an updated version of the manuscript originally published in the Deutsches Ärzteblatt. When applying these recommendations, it is important to consider that intensive care patients are very complex; therefore, the applicability of these principles must be assessed on an individual basis and, where necessary, modified appropriately.
Assuntos
Cuidados Críticos/normas , Medicina Interna/normas , Guias de Prática Clínica como Assunto/normas , Sociedades Médicas/normas , Alemanha , Humanos , Medicina de Precisão/normasRESUMO
The "choosing wisely" recommendations of the German Society of Internal Medicine (DGIM) and its specialist societies address diagnostic and therapeutic procedures, which are of particular medical importance but applied too often or too rarely in clinical practice. The aim is to further improve treatment of patients. Important topics of overuse and insufficient treatment related to the diagnostics, therapy, prevention and exclusion of infectious diseases could be identified. These topics not only play an important role in the discipline of infectious diseases but are also relevant for other internal medical disciplines. These topics related to infectious diseases have also been integrated into the recommendations of the German Society of Gastroenterology, Digestive and Metabolic Diseases as well as the German Societies for Internal Intensive Care and Emergency Medicine, for Pneumology, for Nephrology and for Rheumatology. The pivotal issues of the recommendations are the inappropriate use of antibiotics and insufficient vaccination rates.
Assuntos
Antibacterianos/uso terapêutico , Infecções Bacterianas/prevenção & controle , Medicina Interna/normas , Guias de Prática Clínica como Assunto , Uso Excessivo de Medicamentos Prescritos/prevenção & controle , Vacinação/normas , Antibacterianos/normas , Infecções Bacterianas/tratamento farmacológico , Humanos , Erros de Medicação/prevenção & controleRESUMO
BACKGROUND: End-of-life care is common in German intensive care units (ICUs) but little is known about daily practice. OBJECTIVES: To study the practice of end-of-life care. METHODS: Prospectively planned, secondary analysis comprising the German subset of the worldwide Ethicus2 Study (2015-2016) including consecutive ICU patients with limitation of life-sustaining therapy or who died. RESULTS: Among 1092 (13.7%) of 7966 patients from 11 multidisciplinary ICUs, 967 (88.6%) had treatment limitations, 92 (8.4%) died with failed CPR, and 33 (3%) with brain death. Among patients with treatment limitations, 22.3% (216/967) patients were discharged alive from the ICU. More patients had treatments withdrawn than withheld (556 [57.5%] vs. 411 [42.5%], pâ¯< 0.001). Patients with treatment limitations were older (median 73 years [interquartile range (IQR) 61-80] vs. 68 years [IQR 54-77]) and more had mental decision-making capacity (12.9 vs. 0.8%), advance directives (28.6 vs. 11.2%), and information about treatment wishes (82.7 vs 33.3%, all pâ¯< 0.001). Physicians reported discussing treatment limitations with patients with mental decision-making capacity and families (91.3 and 82.6%, respectively). Patient wishes were unknown in 41.3% of patients. The major reason for decision-making was unresponsiveness to maximal therapy (34.6%). CONCLUSIONS: Treatment limitations are common, based on information about patients' wishes and discussion between stakeholders, patients and families. However, our findings suggest that treatment preferences of nearly half the patients remain unknown which affects guidance for treatment decisions.
Assuntos
Cuidados para Prolongar a Vida , Assistência Terminal , Humanos , Unidades de Terapia Intensiva , Suspensão de Tratamento , Morte Encefálica , Tomada de DecisõesRESUMO
PURPOSE: Ultrasound is a widely used diagnostic tool. In medical education, it can be used to teach sonographic anatomy as well as the basics of ultrasound diagnostics. Some medical schools have begun implementing student tutor-led teaching sessions in sonographic abdominal anatomy in order to meet the growing demand in ultrasound teaching. However, while this teaching concept has proven to be feasible and well accepted, there is limited data regarding its effectiveness. We investigated whether student tutors teach sonographic anatomy as effectively as faculty staff sonographers. MATERIALS AND METHODS: 50 medical students were randomly assigned to one of two groups. 46 of these could be included in the analysis. One group was taught by student tutors (ST) and the other by a faculty staff sonographer (FS). Using a pre/post-test design, students were required to locate and label 15 different abdominal structures. They printed out three pictures in three minutes and subsequently labeled the structures they were able to identify. The pictures were then rated by two blinded faculty staff sonographers. A mean difference of one point in the improvement of correctly identified abdominal structures between the pre-test and post-test among the two groups was regarded as equivalent. RESULTS: In the pre-test, the ST (FS) correctly identified 1.6 ± 1.0 (2.0 ± 1.1) structures. Both the ST and FS group showed improvement in the post-test, correctly identifying 7.8 ± 2.8 vs. 8.9 ± 2.9 structures, respectively (p < .0001 each). Comparing the improvement of the ST (6.2 ± 2.8 structures) versus the FS (6.9 ± 3.2) showed equivalent results between the two groups (p < .05 testing for equivalence). CONCLUSION: Basic abdominal sonographic anatomy can be taught effectively by student tutors.
Assuntos
Abdome/diagnóstico por imagem , Anatomia Transversal/educação , Educação de Graduação em Medicina , Docentes de Medicina , Grupo Associado , Estudantes de Medicina , Ultrassonografia , Adulto , Atitude do Pessoal de Saúde , Benchmarking , Competência Clínica , Feminino , Alemanha , Humanos , Masculino , Mentores , Estudos ProspectivosRESUMO
BACKGROUND: Acute kidney injury (AKI) is a common and serious complication of acute life-threatening diseases. OBJECTIVES: The aim of this study was to investigate the effect of acute renal failure on mortality in intensive care patients, the need for renal replacement therapy at discharge, and the effect on long-term mortality. MATERIAL AND METHODS: Evaluation of 118 patient cases with dialysis-dependent acute renal failure between November 2016 and December 2017 admitted to a medical intensive care unit (ICU) at the University Hospital Tübingen, Germany. Dialysis at discharge and 1year mortality were defined as the primary endpoints. The secondary endpoint was need for continuous renal replacement after 18 months. RESULTS: In 118 patients, renal replacement modality by means of hemodialysis became necessary. A mortality rate of 45.8% (54/118) was found in patients requiring dialysis. Of the 64 surviving dialysis-dependent patients, 35.9% were still dependent on renal replacement therapy at the time of discharge. The 1year mortality rate was significantly higher in patients that still required dialysis at the time of discharge (pâ¯= 0.004). At 18-month follow-up, seven patients (10.9%) were still on renal replacement therapy. At this time, dialysis was significantly more frequent in patients with dialysis at the time of discharge than in dialysis-free patients (7.1% vs. 71.4%, pâ¯= 0.001). CONCLUSION: Severe episodes of AKI requiring renal replacement therapy in the setting of an ICU are associated with increased mortality 1 year after discharge and an increased requirement for renal replacement 18 months after discharge.
Assuntos
Diálise Renal , Insuficiência Renal , Alemanha , Humanos , Unidades de Terapia IntensivaRESUMO
Medical intensive care medicine treats patients with severe, potentially life-threatening diseases covering the complete spectrum of internal medicine. The qualification in medical intensive care medicine requires a broad spectrum of knowledge and skills in medical intensive care medicine, but also in the general field of internal medicine. Both sides of the coin must be taken into account, the treatment with life-sustaining strategies of the acute illness of the patient and also the treatment of patient's underlying chronic diseases. The indispensable foundation of medical intensive care medicine as described in this curriculum includes basic knowledge and skills (level of competence I-III) as well as of behavior and attitudes. This curriculum is primarily dedicated to the internist in advanced training in medical intensive care medicine. However, this curriculum also intends to reach trainers in intensive care medicine and also the German physician chambers with their examiners, showing them which knowledge, skills as well as behavior and attitudes should be taught to trainees according to the education criteria of the German Society of Medical Intensive Care and Emergency Medicine (DGIIN).
Assuntos
Medicina de Emergência , Cuidados Críticos , Currículo , Medicina de Emergência/educação , Humanos , Medicina InternaRESUMO
Intensive care and emergency medicine are extremely important for the treatment of patients with acute and severe medical conditions. While other internal medicine specialties are progressively focused on specific organ systems or diseases, rotations of residents into the intensive care unit (ICU) or the emergency department (ED) are an important part of their training in general internal medicine. Here they can acquire many of the diagnostic and therapeutic skills required in their curriculum. All internal medicine residents in Germany therefore must complete at least a 6 month rotation in the ICU and the ED. For training programs in general internal medicine, the German Society for Medical Intensive Care and Emergency Medicine (Deutsche Gesellschaft für Internistische Intensivmedizin und Notfallmedizin) asks the German State Medical Councils to accept rotations in the ICU and the ED for 15 months each. After adding an ICU or ED fellowship, these internists would be ideally qualified for much needed attending and leadership positions in the ICUs and EDs and would have a better perspective for a scientific career in these fields. In addition, ICU and ED fellowships of internists from other specialties should be supported.
Assuntos
Medicina de Emergência , Cuidados Críticos , Alemanha , Humanos , Unidades de Terapia Intensiva , Medicina InternaRESUMO
BACKGROUND: Since 2010, the number of organ donations has decreased by 30% in Germany; however, stricter organizational structures in clinics and improved payment for hospital services associated with organ removal should increase the current decline in the number of organ donations in Germany. In addition, the Federal Minister of Health proposed introduction of the double presumed consent solution for organ donation. This proposal is currently being discussed very controversially. Against this background, we conducted an online survey of all members of the German Society of Medical Intensive Care and Emergency Medicine (DGIIN) in order to evaluate the attitude towards organ donation. METHOD: The present work is an anonymous online survey among the members of DGIIN, which took place from 10-23 September 2018. In addition to a few demographic queries, the personal opinion on the regulation of organ donation was collected. RESULTS: A total of 1019 (51.9%) of 1964 invited DGIIN members took part at the survey: 79.3% of the participants were male; average age 47.5⯱ 11.2 years; 97.7% were physicians, of whom 89.2% were specialists and 62.7% had the additional degree in critical care; 20.6% voted for the current decision-making solution, 43.1% for the presumed consent, 33.1% for the double presumed consent, whereas 3.2% of the respondents were uncertain in their decision. CONCLUSION: A clear majority of the surveyed members of DGIIN support the concept of presumed consent.
Assuntos
Medicina de Emergência , Obtenção de Tecidos e Órgãos , Adulto , Cuidados Críticos , Alemanha , Humanos , Masculino , Pessoa de Meia-Idade , Consentimento Presumido , Inquéritos e Questionários , Doadores de TecidosRESUMO
BACKGROUND: Compared to other countries, Germany has the highest number of intensive care unit (ICU) beds, but, despite this, a shortage in ICU care is evident. Currently, little comprehensive data on ICU staffing and on subsequent closure of ICU beds are available. The current survey therefore aimed to systematically investigate the closure of ICU beds. METHOD: A survey was performed among authorized professional trainers in ICU medicine. RESULTS: Overall, a shortage of ICU beds following bed closure was evident in 76% of all ICU floors with 22% reporting daily ICU bed closure. In 47%, two ICU beds were not available. Emergency care was unrestricted in only 18%, while restrictions were reportedly frequent or even constant in 30%. The main reasons for ICU bed closure were the unavailability of ICU nurses (44%) and the co-existing unavailability of nurses and physicians (19%). On average, the nurse/patient ratio was 1:2.5 in the morning, 1:2.6 in the afternoon, and 1:3.1 in the night shift. CONCLUSIONS: ICU bed closure regularly occurs in Germany. The underlying main reason has been identified to be the unavailability of ICU nursing staff. This is suggested to directly interfere with emergency care. For this reason, an action plan is urgently needed.
Assuntos
Cuidados Críticos , Recursos Humanos de Enfermagem Hospitalar , Alemanha , Número de Leitos em Hospital , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Recursos Humanos de Enfermagem Hospitalar/provisão & distribuição , Inquéritos e QuestionáriosRESUMO
In the last decade, extracorporeal organ assist devices (extracorporeal membrane oxygenation [ECMO]) have been increasingly applied to treat the most severe forms of respiratory failure and cardiogenic shock, although the underlying scientific evidence is still limited and the methods carry a high risk of complications despite all technical improvements. The selection of those patients who most benefit from these devices is still a great challenge for intensivists and all other involved disciplines. Besides the severity of the acute organ failure, it is important to thoroughly evaluate etiology and treatment options of the underlying disease, comorbidities, and the functional status of the patients in an interdisciplinary team. This also includes ethical challenges. Because of the complexity of the treatment and the high organizational demands it is reasonable to concentrate ECMO treatments in specifically qualified centers and to promote a comprehensive scientific analysis of the treatment data.
Assuntos
Oxigenação por Membrana Extracorpórea , Insuficiência Respiratória , Choque Cardiogênico , Humanos , Insuficiência Respiratória/terapia , Choque Cardiogênico/terapia , Resultado do TratamentoRESUMO
The reimbursement of intensive care and nursing services in the German health system is based on the diagnosis-related groups (G-DRG) system. Due to the lack of a central hospital planning, the GDRG system has become the most important influence on the development of the German health system. Compared to other countries, intensive care in Germany is characterized by a high number of intensive care beds, a low nurse-to-patient ratio, no official definition of the level of care, and a minimal available data set from intensive care units (ICUs). Under the given circumstances, a shortage of qualified intensive care nurses and physicians is currently the largest threat for intensive care in Germany. To address these deficiencies, we suggest the following measures: (1) Integration of ICUs into the levels of care which are currently developed for emergency centers at hospitals. (2) Mandatory collection of structured data sets from all ICUs including quality criteria. (3) A reform of intensive care and nursing reimbursement under consideration of adequate staffing in the individual ICU. (4) Actions to improve ICU staffing and qualification.
Assuntos
Cuidados Críticos , Grupos Diagnósticos Relacionados , Reembolso de Seguro de Saúde , Cuidados Críticos/economia , Alemanha , Humanos , Unidades de Terapia Intensiva , MédicosRESUMO
Extracorporeal cardiopulmonary resuscitation (eCPR) may be considered as a rescue attempt for highly selected patients with refractory cardiac arrest and potentially reversible etiology. Currently there are no randomized, controlled studies on eCPR, and valid predictors of benefit and outcome which might guide the indication for eCPR are lacking. Currently selection criteria and procedures differ across hospitals and standardized algorithms are lacking. Based on expert opinion, the present consensus statement provides a proposal for a standardized treatment algorithm for eCPR.
Assuntos
Reanimação Cardiopulmonar , Oxigenação por Membrana Extracorpórea , Parada Cardíaca , Consenso , Parada Cardíaca/terapia , Humanos , Seleção de PacientesRESUMO
Arterial gene transfer represents a novel strategy that is potentially applicable to a variety of cardiovascular disorders. Attempts to perform arterial gene transfer using nonviral vectors have been compromised by a low transfection efficiency. We investigated the hypothesis that cellular proliferation induced by arterial injury could augment gene expression after liposome-mediated gene transfer. Nondenuded and denuded rabbit arterial strips were maintained in culture for up to 21 d, after which transfection was performed with a mixture of the plasmid encoding firefly luciferase and cationic liposomes. In non-denuded arteries, the culture interval before transfection did not affect the gene expression. In contrast, denuded arteries cultured for 3-14 d before transfection yielded 7-13-fold higher expression (vs. day 0; P < 0.005). Transfection was then performed percutaneously to the iliac arteries of live rabbits with or without antecedent angioplasty. Gene expression increased when transfection was performed 3-7 d postangioplasty (P < 0.05). Proliferative activity of neointimal cells assessed in vitro by [3H]thymidine incorporation, and in vivo by immunostaining for proliferating cell nuclear antigen, increased and declined in parallel with gene expression. These findings thus indicate that the expression of liposome-mediated arterial gene transfer may be augmented in presence of ongoing cellular proliferation.
Assuntos
Aorta Torácica/lesões , Aorta Torácica/metabolismo , Cateterismo/efeitos adversos , Expressão Gênica , Luciferases/biossíntese , Músculo Liso Vascular/metabolismo , Transfecção/métodos , Animais , Aorta Torácica/citologia , Divisão Celular , Portadores de Fármacos , Terapia Genética/métodos , Lipossomos , Masculino , Músculo Liso Vascular/citologia , Músculo Liso Vascular/lesões , Técnicas de Cultura de Órgãos , Plasmídeos/administração & dosagem , CoelhosRESUMO
Point-of-care ultrasound in acute care medicine is a prerequisite for diagnosis and therapy monitoring of critically ill patients. There is currently no uniform education strategy for medical intensive care and emergency medicine. As part of the basic level, the trainee takes theoretical and clinical training covering abdominal and thoracic ultrasonography and focused cardiovascular ultrasound. In a second step, special knowledge and skills can be acquired at an expert level. This two-stage concept is intended to guarantee quality assurance in ultrasound education in medical intensive care and emergency medicine.
Assuntos
Cuidados Críticos , Estado Terminal/terapia , Medicina de Emergência/educação , Sistemas Automatizados de Assistência Junto ao Leito , Ultrassonografia , Currículo , Alemanha , Humanos , Sociedades MédicasRESUMO
Severe infections are a common cause of death in patients suffering from systemic lupus erythematosus (SLE). We here report on a fatal multidrug-resistant Acinetobacter baumannii sepsis in a patient with newly diagnosed SLE, who had to be treated with immunosuppressants due to lupus nephritis. Detailed analysis of the patient's history revealed that colonisation probably had occurred during a recent hospitalisation of the patient in the Mediterranean region. E-test analysis indicated that resistance to carbapenems was mediated by a plasmid-encoded metallo-beta-lactamase. We conclude that travel history including previously visited health care facilities always should be carefully considered for decisions on anti-infective therapy, as travel activities increasingly facilitate spread of antimicrobial resistances.
Assuntos
Infecções por Acinetobacter/microbiologia , Acinetobacter baumannii/efeitos dos fármacos , Farmacorresistência Bacteriana Múltipla , Lúpus Eritematoso Sistêmico/complicações , Sepse/microbiologia , Viagem , Acinetobacter baumannii/enzimologia , Acinetobacter baumannii/genética , Adulto , Antibacterianos/farmacologia , Carbapenêmicos/farmacologia , Evolução Fatal , Feminino , Grécia , Humanos , beta-Lactamases/genéticaRESUMO
BACKGROUND: Catecholamines with vasopressor and inotropic effects are commonly used in intensive care medicine. The aim of this review is to explain some of the physiologic actions on which a catecholamine therapy is based, but also to elucidate the risks which are associated with an uncritical and excessive use of these drugs. SIDE EFFECTS: Emphasis is placed on the myocardial damage triggered by adrenergic overstimulation. There is considerable evidence that in conditions of severe heart failure, myocardial ischemia as well as cardiogenic and septic shock especially the use of catecholamines with predominant ß-adrenergic effects (epinephrine, dobutamine, dopamine) can have a negative clinical impact. A simple cardiac risk marker might be a tachycardia. ADMINISTRATION: Vasopressor therapy with norepinephrine, based on individually applied perfusion parameters (e.g., urine output, lactate), however, seems justified in many conditions of shock and hemodynamic instability during deep analgosedation. In terms of a cardioprotective therapy, the administration of catecholamines, however, should always be reevaluated and titrated to the minimum deemed necessary.
Assuntos
Catecolaminas/uso terapêutico , Cuidados Críticos/métodos , Cardiotônicos/uso terapêutico , Sedação Consciente/métodos , Contraindicações , Hemodinâmica/efeitos dos fármacos , Humanos , Fatores de Risco , Choque/tratamento farmacológico , Vasoconstritores/uso terapêuticoRESUMO
In this paper the German Society for Medical Intensive Care Medicine and Emergency Medicine (DGIIN) provides statements regarding the importance and advancement of Medical Intensive Care Medicine within the structures of Internal Medicine in Germany. Of pivotal importance are the training of medical intensivists, the cooperation with intensivists from other disciplines and the collaboration with emergency departments. In order to fulfil the various and challenging tasks in patient care, training, research and medical education competently and on an international level, more intensivists in leading positions especially in academic institutions are essential.