[Extracorporeal Cardiopulmonary Resuscitation(ECPR) - the Future?] / Extrakorporale kardiopulmonale Reanimation (ECPR) ­ die Zukunft?

In recent years, invasive resuscitation methods utilizing veno-arterial extracorporeal membrane oxygenation (VA-ECMO) have gained significant attention. Despite advances in traditional resuscitation measures, out-of-hospital cardiac arrest (OHCA) mortality remains high. In the context of extracorporeal cardiopulmonary resuscitation (ECPR), VA-ECMO therapy offers a promising approach by providing circulatory support during cardiac arrest, allowing time for diagnostic evaluation and targeted therapy. However, patient selection for ECPR remains a challenge, relying on various factors including initial rhythm, duration of no-flow and low-flow states, as well as presence of reversible causes.Recent studies such as the ARREST, Prague OHCA and INCEPTION trials have investigated the efficacy of ECPR in OHCA patients, yielding mixed results. While the ARREST trial demonstrated a survival benefit with ECPR, the Prague OHCA and INCEPTION trials showed varying outcomes, reflecting the complexity of patient selection and treatment strategies. Despite inherent risks and complications associated with ECPR, it may offer a potential survival advantage under optimal conditions.Future directions in ECPR involve the development of innovative treatment protocols such as the CARL therapy, which incorporates specialized ECMO systems and tailored perfusion solutions. Early studies indicate promising outcomes with CARL therapy, emphasizing the importance of a well-coordinated and structured approach to ECPR implementation.In summary, ECPR shows promise in improving survival rates for OHCA patients within a well-organized healthcare system. However, further research is needed to refine patient selection criteria and optimize treatment protocols, ultimately enhancing patient outcomes in cardiac arrest scenarios.

[Post Resuscitation Care]. / Post Resuscitation Care ­ Postreanimationsbehandlung.

After successful resuscitation, further treatment has a decisive influence regarding patient outcome. Not only overall survival, but also the neurological outcome that is crucial for patients' quality of life can be positively influenced by optimized post-cardiac arrest treatment. The management of various consequences of post-cardiac arrest syndrome is discussed in the current version of the ERC-guidelines in the chapter "post resuscitation care". A step-by-step approach based on an algorithm provides the necessary structure. The immediate treatment and stabilization of patients after ROSC is followed by the diagnosis of the triggering pathology in order to initiate adequate therapy. During the subsequent intensive care treatment, the focus is on optimizing neurological recovery.

The German Resuscitation Registry - Epidemiological data for out-of-hospital and in-hospital cardiac arrest.

Introduction: The German Resuscitation Registry was started in 2007 and collects data on out-of-hospital as well as in-hospital cardiac arrest and resuscitation. It has collected more than 400.000 datasets till today. Methods: The German Resuscitation Registry (GRR) is a voluntary quality improvement tool and research tool for out-of-hospital and in-hospital resuscitation as well as in-hospital emergency treatment. It collects data for initial treatment, in-hospital care as well as long-term outcome in an online database. For risk stratification two scores have been developed, published, and implemented. The participants are getting annual and monthly or quarterly reports in addition to the standardized online, 24/7 available analyzing options. An annual public report is published as well. We are reporting on the OHCA annual report of 2022. Results: In 2022 the incidence of CPR started or continued by EMS was 77.6/100.000 inhabitants/year. The mean age was 70.2 years and 66.7% were male bystanders who started CPR in 51.3%. The average response time for the first EMS vehicle to arrive on scene was 6:55 min.In 57.9% of the cases, they had a presumed cardiac cause. The primary outcome, return-of-spontaneous circulation (ROSC) was achieved in 42.1%. Discussion: With its more than 450.000 included datasets, the GRR is an established tool for quality improvement and research in Germany and internationally. The results for the incidence of OHCA and outcome from 2022 are compared to EuReCa TWO data ranging in the upper third of European countries. Furthermore, the GRR has contributed to increasing knowledge of OHCA by conducting and publishing research e.g. on epidemiology, airway management, and medication of OHCA.

Intraoperative haemodynamic monitoring and management of adults having non-cardiac surgery: Guidelines of the German Society of Anaesthesiology and Intensive Care Medicine in collaboration with the German Association of the Scientific Medical Societies.

Haemodynamic monitoring and management are cornerstones of perioperative care. The goal of haemodynamic management is to maintain organ function by ensuring adequate perfusion pressure, blood flow, and oxygen delivery. We here present guidelines on "Intraoperative haemodynamic monitoring and management of adults having non-cardiac surgery" that were prepared by 18 experts on behalf of the German Society of Anaesthesiology and Intensive Care Medicine (Deutsche Gesellschaft für Anästhesiologie und lntensivmedizin; DGAI).

[Anaesthesia for Hybrid Procedures]. / Anästhesie für Hybrid-Prozeduren.

The development and implementation of the hybrid operating theatre over the last decade is one of the most innovative advancements in the field of medical interdisciplinary treatment options. The hybrid operating theatre allows the combination of minimally invasive surgery and interventional procedures using the benefits of modern imaging technologies. Therefore, it will be of increasing interest for different kinds of surgical disciplines in the future. In Germany, the hybrid operating theatre is mainly used in the field of transcatheter based heart valve procedures and in the field of vascular surgery cooperating with interventional radiology. Managing this special patient population is a highly challenging task for all players in this setting, especially for the cardiac surgeon, the cardiologist, and the anaesthesiologist. Only close interdisciplinary cooperation ensures optimal treatment. The impact of recent developments in the field of transcatheter based heart valve procedures on anaesthesia management will be addressed in this article.

[Intensive Care in Heart Surgery - is All Now Different?] / Intensivtherapie in der Herzchirurgie ­ alles anders?

With approximately 100000 operations performed in Germany per year, cardiac surgery is among the surgical specialties that require intensive care tratment most frequently. Although all therapeutic aspects of ICU treatment are of high importance among cardiac surgery patients, there is a focus on hemodynamics with the overarching goal of sufficient oxygen delivery. Patients undergoing cardiac surgery are particularily prone to hemodynamic instability and low cardiac output syndrome, potentially culminating into cardiogenic shock. This article presents an overview of essential elements of intensive care medicine in cardiac surgery, paying special attention to hemodynamic monitoring, low cardiac output syndrome, inotropy, cardiac arrhyhmia, perioperative myocardial infarction, and patient blood management.

Is Dementia Associated with COVID-19 Mortality? A Multicenter Retrospective Cohort Study Conducted in 50 Hospitals in Germany.

BACKGROUND: Dementia has been identified as a major predictor of mortality associated with COVID-19. OBJECTIVE: The objective of this study was to investigate the association between dementia and mortality in COVID-19 inpatients in Germany across a longer interval during the pandemic. METHODS: This retrospective study was based on anonymized data from 50 hospitals in Germany and included patients with a confirmed COVID-19 diagnosis hospitalized between March 11, 2020 and July, 20, 2022. The main outcome of the study was the association of mortality during inpatient stays with dementia diagnosis, which was studied using multivariable logistic regression adjusted for age, sex, and comorbidities as well as univariate logistic regression for matched pairs. RESULTS: Of 28,311 patients diagnosed with COVID-19, 11.3% had a diagnosis of dementia. Prior to matching, 26.5% of dementia patients and 11.5% of non-dementia patients died; the difference decreased to 26.5% of dementia versus 21.7% of non-dementia patients within the matched pairs (n = 3,317). This corresponded to an increase in the risk of death associated with dementia (OR = 1.33; 95% CI: 1.16-1.46) in the univariate regression conducted for matched pairs. CONCLUSION: Although dementia was associated with COVID-19 mortality, the association was weaker than in previously published studies. Further studies are needed to better understand whether and how pre-existing neuropsychiatric conditions such as dementia may impact the course and outcome of COVID-19.

Comparison of machine learning methods with logistic regression analysis in creating predictive models for risk of critical in-hospital events in COVID-19 patients on hospital admission.

BACKGROUND: Machine learning (ML) algorithms have been trained to early predict critical in-hospital events from COVID-19 using patient data at admission, but little is known on how their performance compares with each other and/or with statistical logistic regression (LR). This prospective multicentre cohort study compares the performance of a LR and five ML models on the contribution of influencing predictors and predictor-to-event relationships on prediction model´s performance. METHODS: We used 25 baseline variables of 490 COVID-19 patients admitted to 8 hospitals in Germany (March-November 2020) to develop and validate (75/25 random-split) 3 linear (L1 and L2 penalty, elastic net [EN]) and 2 non-linear (support vector machine [SVM] with radial kernel, random forest [RF]) ML approaches for predicting critical events defined by intensive care unit transfer, invasive ventilation and/or death (composite end-point: 181 patients). Models were compared for performance (area-under-the-receiver-operating characteristic-curve [AUC], Brier score) and predictor importance (performance-loss metrics, partial-dependence profiles). RESULTS: Models performed close with a small benefit for LR (utilizing restricted cubic splines for non-linearity) and RF (AUC means: 0.763-0.731 [RF-L1]); Brier scores: 0.184-0.197 [LR-L1]). Top ranked predictor variables (consistently highest importance: C-reactive protein) were largely identical across models, except creatinine, which exhibited marginal (L1, L2, EN, SVM) or high/non-linear effects (LR, RF) on events. CONCLUSIONS: Although the LR and ML models analysed showed no strong differences in performance and the most influencing predictors for COVID-19-related event prediction, our results indicate a predictive benefit from taking account for non-linear predictor-to-event relationships and effects. Future efforts should focus on leveraging data-driven ML technologies from static towards dynamic modelling solutions that continuously learn and adapt to changes in data environments during the evolving pandemic. TRIAL REGISTRATION NUMBER: NCT04659187.

Impact of COVID-19 on out-of-hospital cardiac arrest: A registry-based cohort-study from the German Resuscitation Registry.

INTRODUCTION: The global COVID-19 pandemic effects people and the health system. Some international studies reported an increasing number of out-of-hospital cardiac arrest (OHCA). Comparable studies regarding the impact of COVID-19 on incidence and outcome of OHCA are not yet available for Germany. MATERIALS AND METHODS: This epidemiological study from the German Resuscitation Registry (GRR) compared a non-pandemic period (01.03.2018-28.02.2019) and a pandemic period (01.03.2020-28.02.2021) regarding the pandemic-related impact on OHCA care. RESULTS: A total of 18,799 cases were included. The incidence of OHCA (non-pandemic 117.9 vs. pandemic period 128.0/100,000 inhabitants) and of OHCA with resuscitation attempted increased (66.0 vs. 69.1/100,000). OHCA occurred predominantly and more often at home (62.8% vs. 66.5%, p<0.001). The first ECG rhythm was less often shockable (22.2% vs. 20.3%, p = 0.03). Fewer cases of OHCA were observed (58.6% vs. 55.6% p = 0.02). Both the bystander resuscitation rate and the proportion of telephone guided CPR remained stable (38.6% vs. 39.8%, p = 0.23; and 22.3% vs. 22.5%, p = 0.77). EMS arrival times increased (08:39 min vs. 09:08 min, p<0.001). Fewer patients reached a return of spontaneous circulation (ROSC) (45.4% vs. 40.9%, p<0.001), were admitted to hospital (50.2% vs. 45.0%, p<0.001), and discharged alive (13.9% vs. 10.2%, p<0.001). DISCUSSION: Survival after OHCA significantly decreased while the bystander resuscitation rate remained stable. However, longer EMS arrival times and fewer cases of witnessed OHCA may have contributed to poorer survival. Any change to EMS systems in the care of OHCA should be critically evaluated as it may mean a real loss of life-regardless of the pandemic situation.

New Insights in the Occurrence of Venous Thromboembolism in Critically Ill Patients with COVID-19-A Large Postmortem and Clinical Analysis.

Critically ill COVID-19 patients are at high risk for venous thromboembolism (VTE), namely deep vein thrombosis (DVT) and/or pulmonary embolism (PE), and death. The optimal anticoagulation strategy in critically ill patients with COVID-19 remains unknown. This study investigated the ante mortem incidence as well as postmortem prevalence of VTE, the factors predictive of VTE, and the impact of changed anticoagulation practice on patient survival. We conducted a consecutive retrospective analysis of postmortem COVID-19 (n = 64) and non-COVID-19 (n = 67) patients, as well as ante mortem COVID-19 (n = 170) patients admitted to the University Medical Center Hamburg-Eppendorf (Hamburg, Germany). Baseline patient characteristics, parameters related to the intensive care unit (ICU) stay, and the clinical and autoptic presence of VTE were evaluated and statistically compared between groups. The occurrence of VTE in critically ill COVID-19 patients is confirmed in both ante mortem (17%) and postmortem (38%) cohorts. Accordingly, comparing the postmortem prevalence of VTE between age- and sex-matched COVID-19 (43%) and non-COVID-19 (0%) cohorts, we found the statistically significant increased prevalence of VTE in critically ill COVID-19 cohorts (p = 0.001). A change in anticoagulation practice was associated with the statistically significant prolongation of survival time (HR: 2.55, [95% CI 1.41-4.61], p = 0.01) and a reduction in VTE occurrence (54% vs. 25%; p = 0.02). In summary, in the autopsy as well as clinical cohort of critically ill patients with COVID-19, we found that VTE was a frequent finding. A change in anticoagulation practice was associated with a statistically significantly prolonged survival time.

[Hemodynamic Monitoring in the ICU: the More Invasive, the Better?] / Hämodynamisches Monitoring auf der Intensivstation: Je invasiver, desto besser?

Less invasive or even completely non-invasive haemodynamic monitoring technologies have evolved during the last decades. However, the invasive devices such as the pulmonary artery catheter and transpulmonary thermodilution technologies are still the clinical gold standard in terms of advanced haemodynamic monitoring, especially in the treatment of critically ill patients. The current data situation regarding the early use of continuous haemodynamic monitoring in this patient population, specifically flow-based variables such as stroke volume to prevent occult hypoperfusion, is overwhelming. However, the effective implementation of these technologies in daily clinical routine is remarkably low. Given the fact that perioperative morbidity and mortality are higher than anticipated, anaesthesiologists and intensivists are in charge to deal with this problem. The recent advances in minimally invasive and non-invasive haemodynamic monitoring technologies may facilitate a more widespread use in the operating theatre and in critical care patients. This review evaluates the significance of invasive, minimally- and non-invasive monitoring devices and their specific haemodynamic variables in this particular field of perioperative medicine.

[Hemodynamic Monitoring 2.0 - What is Possible on Normal Wards?] / Hämodynamisches Monitoring 2.0 ­ was ist auf Normalstation möglich?

Life threatening events after surgery often occur on the ward. These events could be prevented by early detection of clinical deterioration of patients' health status during ward care. Therefore, an adequate monitoring could help to identify patients at risk, since there is an imbalance of monitoring intensity and the occurrence of life-threatening events during hospital stay.Additional monitoring on the general ward could lead to more patient safety. The practicability of additional monitoring needs to be considered, and therefore the use of available monitoring systems on the ward is limited. Capillary refill time (CRT) and the passive leg raise test (PLR) seem to be usable intermittent monitoring techniques.Continuous monitoring systems ensure a better detection of unwanted events and hemodynamic trends. However, the increased workload for the nursing staff and tethered monitors are unfavorable. Future trends of developing wireless monitoring systems are of paramount importance in this respect. Controlling artefacts is crucial for the successful balance between false alarms and "missed events". An adequate reaction is needed when detecting adverse events to avoid a "failure to rescue".

Prognostic Impact of Acute Cardiovascular Events in COVID-19 Hospitalized Patients-Results from the CORONA Germany Study.

BACKGROUND: Acute myocardial injury (AMJ), assessed by elevated levels of cardiac troponin, is associated with fatal outcome in coronavirus disease 2019 (COVID-19). However, the role of acute cardiovascular (CV) events defined by clinical manifestation rather than sole elevations of biomarkers is unclear in hospitalized COVID-19 patients. OBJECTIVE: The aim of this study was to investigate acute clinically manifest CV events in hospitalized COVID-19 patients. METHODS: From 1 March 2020 to 5 January 2021, we conducted a multicenter, prospective, epidemiological cohort study at six hospitals from Hamburg, Germany (a portion of the state-wide 45-center CORONA Germany cohort study) enrolling all hospitalized COVID-19 patients. Primary endpoint was occurrence of a clinically manifest CV-event. RESULTS: In total, 132 CV-events occurred in 92 of 414 (22.2%) patients in the Hamburg-cohort: cardiogenic shock in 10 (2.4%), cardiopulmonary resuscitation in 12 (2.9%), acute coronary syndrome in 11 (2.7%), de-novo arrhythmia in 31 (7.5%), acute heart-failure in 43 (10.3%), myocarditis in 2 (0.5%), pulmonary-embolism in 11 (2.7%), thrombosis in 9 (2.2%) and stroke in 3 (0.7%). In the Hamburg-cohort, mortality was 46% (42/92) for patients with a CV-event and 33% (27/83) for patients with only AMJ without CV-event (OR 1.7, CI: (0.94-3.2), p = 0.077). Mortality was higher in patients with CV-events (Odds ratio(OR): 4.8, 95%-confidence-interval(CI): [2.9-8]). Age (OR 1.1, CI: (0.66-1.86)), atrial fibrillation (AF) on baseline-ECG (OR 3.4, CI: (1.74-6.8)), systolic blood-pressure (OR 0.7, CI: (0.53-0.96)), potassium (OR 1.3, CI: (0.99-1.73)) and C-reactive-protein (1.4, CI (1.04-1.76)) were associated with CV-events. CONCLUSION: Hospitalized COVID-19 patients with clinical manifestation of acute cardiovascular events show an almost five-fold increased mortality. In this regard, the emergence of arrhythmias is a major determinant.

[Monitoring of Fluid Therapy]. / Monitoring und Steuerung der Flüssigkeitstherapie ­ wozu und womit?

Fluid and volume therapy is of paramount importance in anaesthesia and intensive care medicine. Fluid replacement as well as volume therapy can cause hypervolemia with deleterious consequences. Therefore, a prerequisite for an adequate volume therapy is the assessment of fluid responsiveness. Several monitoring techniques for evaluation of volume status and of volume responsiveness are currently used. However, there are several limitations of the different monitoring techniques that the user should be aware of. An algorithm can be helpful for a structured approach in monitoring volume therapy.