Your browser doesn't support javascript.
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 132
Filtrar
Mais filtros










Base de dados
Intervalo de ano de publicação
1.
Pneumologie ; 73(12): 723-814, 2019 Dec.
Artigo em Alemão | MEDLINE | ID: mdl-31816642

RESUMO

Mechanical ventilation (MV) is an essential part of modern intensive care medicine. MV is performed in patients with severe respiratory failure caused by insufficiency of respiratory muscles and/or lung parenchymal disease when/after other treatments, (i. e. medication, oxygen, secretion management, continuous positive airway pressure or nasal highflow) have failed.MV is required to maintain gas exchange and to buy time for curative therapy of the underlying cause of respiratory failure. In the majority of patients weaning from MV is routine and causes no special problems. However, about 20 % of patients need ongoing MV despite resolution of the conditions which precipitated the need for MV. Approximately 40 - 50 % of time spent on MV is required to liberate the patient from the ventilator, a process called "weaning."There are numberous factors besides the acute respiratory failure that have an impact on duration and success rate of the weaning process such as age, comorbidities and conditions and complications acquired in the ICU. According to an international consensus conference "prolonged weaning" is defined as weaning process of patients who have failed at least three weaning attempts or require more than 7 days of weaning after the first spontaneous breathing trial (SBT). Prolonged weaning is a challenge, therefore, an inter- and multi-disciplinary approach is essential for a weaning success.In specialised weaning centers about 50 % of patients with initial weaning failure can be liberated from MV after prolonged weaning. However, heterogeneity of patients with prolonged weaning precludes direct comparisons of individual centers. Patients with persistant weaning failure either die during the weaning process or are discharged home or to a long term care facility with ongoing MV.Urged by the growing importance of prolonged weaning, this Sk2-guideline was first published in 2014 on the initiative of the German Respiratory Society (DGP) together with other scientific societies involved in prolonged weaning. Current research and study results, registry data and experience in daily practice made the revision of this guideline necessary.The following topics are dealt with in the guideline: Definitions, epidemiology, weaning categories, the underlying pathophysiology, prevention of prolonged weaning, treatment strategies in prolonged weaning, the weaning unit, discharge from hospital on MV and recommendations for end of life decisions.Special emphasis in the revision of the guideline was laid on the following topics:- A new classification of subgroups of patients in prolonged weaning- Important aspects of pneumological rehabilitation and neurorehabilitation in prolonged weaning- Infrastructure and process organization in the care of patients in prolonged weaning in the sense of a continuous treatment concept- Therapeutic goal change and communication with relativesAspects of pediatric weaning are given separately within the individual chapters.The main aim of the revised guideline is to summarize current evidence and also expert based- knowledge on the topic of "prolonged weaning" and, based on the evidence and the experience of experts, make recommendations with regard to "prolonged weaning" not only in the field of acute medicine but also for chronic critical care.Important addressees of this guideline are Intensivists, Pneumologists, Anesthesiologists, Internists, Cardiologists, Surgeons, Neurologists, Pediatricians, Geriatricians, Palliative care clinicians, Rehabilitation physicians, Nurses in intensive and chronic care, Physiotherapists, Respiratory therapists, Speech therapists, Medical service of health insurance and associated ventilator manufacturers.


Assuntos
Guias de Prática Clínica como Assunto , Pneumologia/normas , Respiração Artificial/métodos , Insuficiência Respiratória/terapia , Desmame do Respirador/métodos , Desmame do Respirador/normas , Criança , Medicina Baseada em Evidências , Alemanha , Serviços de Assistência Domiciliar , Humanos , Insuficiência Respiratória/diagnóstico , Sociedades Médicas
2.
Pneumologie ; 73(11): 670-676, 2019 Nov.
Artigo em Alemão | MEDLINE | ID: mdl-31715635

RESUMO

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.


Assuntos
Cuidados Críticos , Serviços de Assistência Domiciliar , Assistência ao Paciente/tendências , Respiração Artificial , Cuidados Críticos/métodos , Cuidados Críticos/tendências , Alemanha , Serviços de Assistência Domiciliar/estatística & dados numéricos , Serviços de Assistência Domiciliar/tendências , Hospitalização , Humanos , Unidades de Terapia Intensiva , Respiração Artificial/métodos , Respiração Artificial/estatística & dados numéricos
3.
Artigo em Alemão | MEDLINE | ID: mdl-30969352

RESUMO

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.

4.
Med Klin Intensivmed Notfmed ; 114(4): 319-326, 2019 May.
Artigo em Alemão | MEDLINE | ID: mdl-30976838

RESUMO

BACKGROUND AND CHALLENGE: Injuries, especially traumatic brain injury, or specific illnesses and their respective sequelae can result in the demise of the patients afflicted despite all efforts of modern intensive care medicine. If in principle organ donation is an option after a patient's death, intensive therapeutic measures are regularly required in order to maintain the homeostasis of the organs. These measures, however, cannot benefit the patient afflicted anymore-which in turn might lead to an ethical conflict between dignified palliative care for him/her and expanded intensive treatment to facilitate organ donation for others, especially if the patient has opted for the limitation of life-sustaining therapies in an advance directive. METHOD: The Ethics Section and the Organ Donation and Transplantation Section of the German Interdisciplinary Association of Critical Care and Emergency Medicine (DIVI) have convened several meetings and a telephone conference and have arrived at a decision-making aid as to the extent of treatment for potential organ donors. This instrument focusses first on the assessment of five individual dimensions regarding organ donation, namely the certitude of a complete and irreversible loss of all brain function, the patient's wishes as to organ donation, his or her wishes as to limiting life-sustaining therapies, the intensity of expanded intensive treatment for organ protection and the odds of its successful attainment. Then, the combination of the individual assessments, as graphically shown in a {Netzdiagramm}, will allow for a judgement as to whether a continuation or possibly an expansion of intensive care measures is ethically justified, questionable or even inappropriate. RESULT: The aid described can help mitigate ethical conflicts as to the extent of intensive care treatment for moribund patients, when organ donation is a medically sound option. NOTE: Gerald Neitzke und Annette Rogge contributed equally to this paper and should be considered co-first authors.


Assuntos
Tomada de Decisões , Medicina de Emergência , Transplante de Órgãos , Obtenção de Tecidos e Órgãos , Cuidados Críticos , Humanos , Transplante de Órgãos/ética , Doadores de Tecidos , Obtenção de Tecidos e Órgãos/ética
7.
Artigo em Alemão | MEDLINE | ID: mdl-30725268

RESUMO

This is a case report of a chest tube incorrectly placed on the healthy left side in a patient with a spontaneous right-sided pneumothorax based on misguiding radiological findings. This erroneous chest tube placement was a result of an inconclusive clinical examination in a patient with a history of pulmonary fibrosis as well as the side-inverted digital production of the chest X­ray. Follow-up chest X­ray after chest tube placement on the wrong side displayed this serious adverse event. To avoid such errors, team training, bedside sonography, and checklists are important tools. Correctly documented radiological images should also be ensured.

8.
Artigo em Inglês | MEDLINE | ID: mdl-30607450

RESUMO

A high incidence of care-relevant psychological problems in critical care medicine has been reported among patients, their families and professional care givers. International guidelines give appropriate recommendations for such care. What is unclear, however, is just how the care and support are provided in day-to-day practice and, in particular, which service providers are responsible for this support. The present care situation was studied in a web-based survey (38% response rate) among all members of the German Society of Medical Intensive Care and Emergency Medicine (DGIIN). Most respondents reported a moderate to substantial need for psychological support of patients in intensive care and a substantial to very substantial need in the case of their family members. The need for support in the case of staff showed a relatively broad scatter in the assessment. Providers of care are mainly the members of the intensive care team themselves, while clinical pastoral counsellors in particular are also involved and, to a lesser extent, counselling or liaison services specializing in psychotherapy.

9.
Med Klin Intensivmed Notfmed ; 114(5): 434-438, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-29632969

RESUMO

Current international and national guidelines promote the use of emergency echocardiography in patients with cardiogenic shock. We assessed whether these recommendations are followed in clinical practice of infarct-related cardiogenic shock patients. For this purpose we conducted a web-based survey among all members of the German Society of Medical Intensive Care and Emergency Medicine (DGIIN); 40% of the DGIIN members completed the survey. Participants reported that in their department emergency echocardiography/ultrasound is performed on most patients in infarct-related cardiogenic shock presenting to the emergency department/chest pain unit or intensive care unit (58.6% versus 81.4%). Only 33% stated that on patients admitted directly to the catheterization laboratory emergency ultrasound/echocardiography is applied in their institution. Local availability of a standardized algorithm was lacking in the majority of departments (77.2%). A great proportion (38.3%) of participants stated that they personally had no formal training in emergency ultrasound. In order to meet the demands of the current guidelines, in addition to integration of ultrasound examinations into diagnostic algorithms, a structured training of all emergency and intensive care physicians is necessary.


Assuntos
Medicina de Emergência , Padrões de Prática Médica , Choque Cardiogênico , Cuidados Críticos , Ecocardiografia/tendências , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Inquéritos e Questionários , Ultrassonografia/tendências
12.
Med Klin Intensivmed Notfmed ; 114(1): 53-55, 2019 02.
Artigo em Alemão | MEDLINE | ID: mdl-30397763

RESUMO

The Ethics Section of the German Interdisciplinary Association of Critical Care and Emergency Medicine (DIVI) recently published a documentation for decisions to withhold or withdraw life-sustaining therapies. The wish to donate organs was not considered explicitly. Therefore the Ethics Section and the Organ Donation and Transplantation Section of the DIVI together with the Ethics Section of the German Society of Medical Intensive Care Medicine and Emergency Medicine worked out a supplementary footnote for the documentation form to address the individual case of a patient's wish to donate organs.

13.
Med Klin Intensivmed Notfmed ; 114(4): 327-333, 2019 May.
Artigo em Alemão | MEDLINE | ID: mdl-29987337

RESUMO

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 no Hospital , Alemanha , Número de Leitos em Hospital , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Recursos Humanos de Enfermagem no Hospital/provisão & distribução , Inquéritos e Questionários
15.
Med Klin Intensivmed Notfmed ; 114(4): 345-349, 2019 May.
Artigo em Alemão | MEDLINE | ID: mdl-29666878

RESUMO

BACKGROUND: This case report presents a case of symptomatic methemoglobinemia (MetHb 31.6%) after inhalation of volatile nitrites (poppers). METHODS: The patient's medical history and symptoms are discussed together with pathophysiology of methemoglobinemia, diagnostics, and antidote therapy. Pulse oxymetry, arterial blood gas analysis, and CO-oximetry receive particular attention as well as antidote therapy with methylene blue. RESULTS: The patient was treated successfully with intravenous methylene blue. Within 60 min methemoglobinemia returned to normal values (MetHb 0.6%). CONCLUSION: Stimulating compounds such as volatile nitrites (poppers) may lead to potentially fatal methemoglobinemia. Swift and accurate diagnosis and targeted therapy with methylene blue can lead to rapid recovery.


Assuntos
Metemoglobinemia , Nitritos , Adulto , Antídotos , Humanos , Masculino , Metemoglobinemia/diagnóstico , Metemoglobinemia/etiologia , Azul de Metileno/uso terapêutico , Nitritos/efeitos adversos , Oximetria
16.
Artigo em Alemão | MEDLINE | ID: mdl-30357421

RESUMO

In rare cases, global cardiac decompensation is the only sign of a relevant endoleak after endovascular aortic repair (EVAR) therapy from a thoracic aortic aneurysm due to a mechanical compression of the left atrium. In this case report, we describe such an unusual course of disease and we point out the importance of early bed-side echocardiography in the emergency department for immediate diagnostic and therapeutic planning.

18.
Med Klin Intensivmed Notfmed ; 113(6): 478-486, 2018 09.
Artigo em Alemão | MEDLINE | ID: mdl-29967938

RESUMO

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 Pacientes
19.
Anaesthesist ; 67(8): 607-616, 2018 08.
Artigo em Alemão | MEDLINE | ID: mdl-30014276

RESUMO

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 , Humanos
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA