[Nationwide exposure model for COVID-19 intensive care unit admission]. / Bundesweites Belastungsmodell für Intensivstationen durch COVID-19.

BACKGROUND: Forecasting models for intensive care occupancy of coronavirus disease 2019 (COVID-19) patients are important in the current pandemic for strategic planning of patient allocation and avoidance of regional overcrowding. They are often trained entirely on retrospective infection and occupancy data, which can cause forecast uncertainty to grow exponentially with the forecast horizon. METHODOLOGY: We propose an alternative modeling approach in which the model is created largely independent of the occupancy data being simulated. The distribution of bed occupancies for patient cohorts is calculated directly from occupancy data from "sentinel clinics". By coupling with infection scenarios, the prediction error is constrained by the error of the infection dynamics scenarios. The model allows systematic simulation of arbitrary infection scenarios, calculation of bed occupancy corridors, and sensitivity analyses with respect to protective measures. RESULTS: The model was based on hospital data and by adjusting only two parameters of data in the Aachen city region and Germany as a whole. Using the example of the simulation of the respective bed occupancy rates for Germany as a whole, the loading model for the calculation of occupancy corridors is demonstrated. The occupancy corridors form barriers for bed occupancy in the event that infection rates do not exceed specific thresholds. In addition, lockdown scenarios are simulated based on retrospective events. DISCUSSION: Our model demonstrates that a significant reduction in forecast uncertainty in occupancy forecasts is possible by selectively combining data from different sources. It allows arbitrary combination with infection dynamics models and scenarios, and thus can be used both for load forecasting and for sensitivity analyses for expected novel spreading and lockdown scenarios.

[Core curriculum Medical intensive care medicine of the German Society of Medical Intensive Care and Emergency Medicine (DGIIN)]. / Curriculum Internistische Intensivmedizin.

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).

[Structure of hospital care for COVID-19 patients up to July 2020 in Germany]. / Stationäre und intensivmedizinische Versorgungsstrukturen von COVID-19-Patienten bis Juli 2020.

BACKGROUND: Hospitalized coronavirus disease 2019 (COVID-19) patients have a high morbidity and mortality and are often dependent on intensive care, especially mechanical ventilation. Little is as yet known about COVID-19 patient allocation. OBJECTIVES: Analysis of the structures of German hospital care for COVID-19 patients up to July 2020 in terms of number of beds and previous ventilation experience. DATA AND METHODS: For the analysis of the care structures, only completed COVID-19 cases in which the virus was detected by a PCR test were evaluated. Claims data from the German Local Health Care Funds (Allgemeine Ortskrankenkassen, AOK) were analysed. The sample includes 17,094 COVID-19 cases that were treated in 1082 hospitals. RESULTS: A total of 77% of all hospitals participated in the treatment COVID-19 patients and 48% of all hospitals provided intensive care for these patients. One half of the hospitals that treated COVID-19 cases cared for 88% of all cases. Although this suggests a centralization effect of COVID-19 cases in specific hospitals, the remaining 12% of the cases were distributed among many hospitals with often very small numbers of cases. Furthermore, 23% of the ventilated COVID-19 cases were treated in hospitals with below-average ventilation experience. CONCLUSIONS: In the context of increasing numbers of infections, it is both necessary to improve the allocation of hospitalized, and therefore potentially ventilated, COVID-19 cases by means of clearly defined and centrally controlled pyramid-type concepts and to continue to care for patients without COVID-19. For Germany, a comprehensive pyramid-type concept with a greater concentration in the best-qualified hospitals seems reasonable for the care of these patients with complex diseases.

[S2k Guideline - Recommendations for Inpatient Therapy of Patients with COVID-19]. / S2k-Leitlinie ­ Empfehlungen zur stationären Therapie von Patienten mit COVID-19.

Since December 2019, the novel coronavirus SARS-CoV-2 (Severe Acute Respiratory Syndrome - Corona Virus-2) has been spreading rapidly in the sense of a global pandemic. This poses significant challenges for clinicians and hospitals and is placing unprecedented strain on the healthcare systems of many countries. The majority of patients with Coronavirus Disease 2019 (COVID-19) present with only mild symptoms such as cough and fever. However, about 6 % require hospitalization. Early clarification of whether inpatient and, if necessary, intensive care treatment is medically appropriate and desired by the patient is of particular importance in the pandemic. Acute hypoxemic respiratory insufficiency with dyspnea and high respiratory rate (> 30/min) usually leads to admission to the intensive care unit. Often, bilateral pulmonary infiltrates/consolidations or even pulmonary emboli are already found on imaging. As the disease progresses, some of these patients develop acute respiratory distress syndrome (ARDS). Mortality reduction of available drug therapy in severe COVID-19 disease has only been demonstrated for dexamethasone in randomized controlled trials. The main goal of supportive therapy is to ensure adequate oxygenation. In this regard, invasive ventilation and repeated prone positioning are important elements in the treatment of severely hypoxemic COVID-19 patients. Strict adherence to basic hygiene, including hand hygiene, and the correct wearing of adequate personal protective equipment are essential when handling patients. Medically necessary actions on patients that could result in aerosol formation should be performed with extreme care and preparation.

Recommendations for treatment of critically ill patients with COVID-19 : Version 3 S1 guideline.

Since December 2019 a novel coronavirus (severe acute respiratory syndrome coronavirus 2, SARS-CoV-2) has rapidly spread around the world resulting in an acute respiratory illness pandemic. The immense challenges for clinicians and hospitals as well as the strain on many healthcare systems has been unprecedented.The majority of patients present with mild symptoms of coronavirus disease 2019 (COVID-19); however, 5-8% become critically ill and require intensive care treatment. Acute hypoxemic respiratory failure with severe dyspnea and an increased respiratory rate (>30/min) usually leads to intensive care unit (ICU) admission. At this point bilateral pulmonary infiltrates are typically seen. Patients often develop a severe acute respiratory distress syndrome (ARDS).So far, remdesivir and dexamethasone have shown clinical effectiveness in severe COVID-19 in hospitalized patients. The main goal of supportive treatment is to ascertain adequate oxygenation. Invasive mechanical ventilation and repeated prone positioning are key elements in treating severely hypoxemic COVID-19 patients.Strict adherence to basic infection control measures (including hand hygiene) and correct use of personal protection equipment (PPE) are essential in the care of patients. Procedures that lead to formation of aerosols should be carried out with utmost precaution and preparation.

[New challenges for intensive care medicine due to climate change and global warming]. / Neue intensivmedizinische Herausforderungen durch Klimawandel und globale Erderwärmung.

BACKGROUND: In the last five decades a continuous increase in the average global temperature has been recorded. Furthermore, natural disasters (e.g. heat waves, severe storms, floods and large forest fires) are becoming more frequent. The impact of global warming and climate change on health involves an increase in respiratory, cardiovascular, renal and cognitive mental diseases. Furthermore, a change in the frequency and patterns of infectious diseases can also be observed in Europe. MATERIAL AND METHODS: This article presents the most important studies that investigated diseases associated with the climate change, with special reference to those that represent a challenge for intensive care medicine. RESULTS: Currently available epidemiological data and statistical extrapolations indicate that diseases resulting from the climate change (acute infection-related respiratory and intestinal diseases, exacerbation of pre-existing pulmonary lesions, heat-related dehydration, cerebral insults and myocardial infarction) are relevant for intensive care medicine. Particular emphasis is placed on a significant increase in acute kidney damage during heat waves. A previously unknown pattern of infectious diseases necessitates new knowledge and targeted management. In some studies, persisting mental impairments were registered during heat waves and natural disasters, e.g. posttraumatic stress disorder. CONCLUSION: Intensive care medicine must be prepared for the challenges due to global warming and climate change. Slow but continuous changes (e.g. rise in temperature) as well as acute changes (e.g. heat waves and natural disasters) will induce an increased need for intensive medical care services (e.g. an increase in the need for renal replacement procedures). Intensive care physicians will need to be familiar with the diagnostics and management of diseases associated with the climate change. An initiative of the specialist societies involved would be welcomed.

[Acute Eosinophilic Pneumonia (AEP) after Hookah Smoking]. / Akute eosinophile Pneumonie (AEP) nach Shisha-Rauchen.

A 27-year-old, previously physically healthy man presented to an emergency department with an acute onset of thoracic pain, dyspnea, non-productive cough and fever. Hours before the onset of symptoms, the patient has smoked tobacco using a waterpipe (spearmint taste, not commercially available in Germany). Due to a progressive respiratory failure the patient required invasive mechanical ventilation. The computertomography scan of the chest showed bilateral diffuse, infiltrative changes. The diagnosis of hookah smoking associated Acute Eosinophilic Pneumonia (AEP) was based on the patient's history, the eosinophilic count in broncho-alveolar lavage and the computertomographic findings. After treatment with corticosteroids, the patient could be extubated after 9 days. The outpatient follow-up revealed a normal lung function testing and X-ray of the chest without any physical sequelae. CONCLUSION: In cases of acute onset of thoracic pain, dyspnea, non-productive cough and fever, acute eosinophilic pneumonia should be considered for differential diagnosis in association with shisha smoking. Severe respiratory lung failure can be successfully treated with corticosteroid therapy and ventilation resulting in full recovery.

[Update and Comment on the German S3 "Clinical Guideline for Treating Acute Respiratory Insufficiency with Invasive Ventilation and Extracorporeal Membrane Oxygenation: Evidence-Based Recommendations"]. / Was hat sich seit Publikation der S3-Leitlinie "Invasive Beatmung und Einsatz extrakorporaler Verfahren" getan?

In 2017 the German Clinical Guideline for Treating Acute Respiratory Insufficiency with Invasive Ventilation and Extracorporeal Membrane Oxygenation: Evidence-Based Recommendations were released. This article highlights emerging data and new concepts which were introduced since 2017. Among others it summarizes the current progress made in evidence-based recommendations of mechanical ventilation and extracorporeal membrane oxygenation (ECMO). In detail, the new evidence for treating severe ARDS with ECMO, phenotyping of ARDS, early neuromuscular blockade and the application of non-invasive ventilation and high-flow oxygen therapy are discussed.

[Presumed consent for organ donation? : A survey among members of the German Society of Medical Intensive Care and Emergency Medicine]. / Widerspruchslösung bei der Organspende? : Eine Umfrage bei Mitgliedern der Deutschen Gesellschaft für internistische Intensivmedizin und Notfallmedizin.

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.

[Evolving Epidemiology of Home Mechanical Ventilation: A Rapidly Growing Challenge for Patient Care]. / Epidemiologische Entwicklung der außerklinischen Beatmung: Eine rasant zunehmende Herausforderung für die ambulante und stationäre Patientenversorgung.

BACKGROUND: Home mechanical ventilation is dramatically evolving in Germany. Patients with non-invasive and invasive ventilation are increasingly treated at home. In-hospital treatment of these patients is also necessary either for control visits or the management of acute medical problems. However, the development of in-hospital patient care, morbidity and mortality of these patients is unknown. METHODS: All patients with long-term dependence on mechanical ventilation for more than three months requiring hospitalisation between 2006 and 2016 were analysed (data obtained from the Federal Statistical Office of Germany). RESULTS: There was an exponential increase in the number of in-patients with long-term dependence of mechanical ventilation. While 24 845 patients were treated in-hospital in 2006, 86 117 patients were treated in 2016. Correspondingly, mortality decreased from 13.2 % (2006) to 5.7 % (2016). In addition, in 2016 47 % of all patients were treated on the intensive care or high dependency care unit. Overall, patients had been severely ill, as there were plenty of medical and neurological co-morbidities. The most common diagnosis was COPD with 58 % of all cases, followed by several cardiology diagnosis. A high number of patients had an impairment of renal function (24 %), in part requiring dialysis. CONCLUSIONS: The rapid development of home mechanical ventilation substantially impacts on the development of the hospital landscape in Germany. The exponential increase of these care-intensive patients is challenging for the health care system and requires a discussion about its limits.

[Indications and limitations of ECMO therapy : Considerations on evidence, treatment decisions and ethical challenges]. / Indikationen und Grenzen der ECMO-Therapie : Überlegungen zur Evidenz, Therapieentscheidung und ethischen Herausforderung.

The present work sheds light on the possibilities and limitations of modern extracorporeal membrane oxygenation (ECMO) therapy in the case of heart or lung failure. Since the number of applications of extracorporeal lung and heart/lung replacement procedures has increased dramatically in the last few years in severely ill patients, decision-making for a meaningful indication and in the course of a possible therapy target change has become particularly difficult, especially with regard to the complex situation in organ transplantation in Germany. An attempt is made to elucidate the dilemma between data from large controlled trials and epidemiological studies and the patients' individuality.

[Impact of nursing staff shortage on intensive care medicine capacity in Germany]. / Auswirkungen des Pflegepersonalmangels auf die intensivmedizinische Versorgungskapazität in Deutschland.

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.

[Interactions between lung and kidney in the critically ill]. / Lunge-Nieren-Interaktionen bei kritisch Kranken.

Interactions between lung and kidney can significantly affect the course of acute diseases, a phenomenon that was first observed in the 1950s by describing pulmonary dysfunction in uremic patients. From animal experiments there is ample evidence for remote lung injury following acute kidney injury (AKI), with an increased risk for the development of pulmonary edema and acute respiratory distress syndrome (ARDS). Coincident ARDS and AKI are associated with higher rates of intubation and mechanical ventilation, significantly prolonged weaning from mechanical ventilation and increased mortality. On the other hand, acute lung diseases and mechanical ventilation can promote the development of AKI and are associated with increased mortality when AKI is also present. These bidirectional interactions may include hemodynamic adverse effects during mechanical ventilation or volume overload as well as the release or decreased clearance and metabolism of proinflammatory mediators (e.g., interleukin-6 and tumor necrosis factor-α), which may induce and aggravate distant organ injury. The aim of this work is to examine the interactions between lung and the kidney in critically ill patients, as well as discuss potential preventive approaches.

[Organ assist devices in the future : Limits and perspectives]. / Organersatz in der Zukunft : Grenzen und Perspektiven.

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.

[Extracorporeal CO2 Elimination (ECCO2R) for Hypercapnic Respiratory Failure: From Pathophysiology to Clinical Application]. / Extrakorporale CO2-Elimination (ECCO2R): von der Pathophysiologie zur klinischen Anwendung beim hyperkapnischen respiratorischen Versagen.

Extracorporeal CO2 removal (ECCO2R) is becoming an increasingly established treatment option for patients with acute severe hypercapnic respiratory failure. Technically, pumpless arterio-venous systems using the natural arterio-venous pressure gradient and also pump-driven veno-venous systems are available. Here, veno-venous ECCO2R has become the preferred technique, as settings for arterio-venous ECCO2R are restricted and side effects are more common with arterio-venous ECCO2R. Using veno-venous ECCO2R with blood flow rates up to 450 ml/min 60 to 80 ml CO2 can be removed per minute corresponding to 20 to 30 % of the total amount of CO2 production. However, in case of very severe hypercapnic respiratory failure with severe respiratory acidosis (pH 7.1 or less) blood flow rates of around 1000 ml/min are required for compensating severe respiratory acidosis corresponding to the elimination of 50 to 60 % of the total amount of CO2 production. Relevant side effects include the activation of blood coagulation and associated bleeding complications. Two recent case-control studies in severely exacerbated COPD patients could demonstrate that intubation rates can be reduced by the application of ECCO2R, but this was associated with non-ignorable side effects. Therefore, randomized controlled trials are urgently needed to more precisely establish the risks and benefits of ECCO2R when aimed at avoiding intubation.