Die geschichtliche Entwicklung der Intensivmedizin in Deutschland

Ohne Zusammenfassung     

Die geschichtliche Entwicklung der Intensivmedizin in Deutschland

Ohne Zusammenfassung     

Die geschichtliche Entwicklung der Intensivmedizin in Deutschland Nachwort zur Themenreihe in Der Anaesthesist

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Patientensicherheit in der Versorgungsforschung

Patient safety is an essential quality criterion for good medical care. A main aim of patient safety interventions is the prevention and/or reduction of adverse events. Various approaches are available for this. The multidisciplinarity in health services research as well as the wide range of methods and topics leads to the fact that health services research is predestined to deal with many of the resulting research questions and with respect to the complexity.     

Grenzen der Versorgungsforschung

Current limitations in health services research (HRS) in Germany are caused by issues of research funding, interest-driven commissioning, and restricted research conditions due to the structural and organizational context of the German health system. Methodological challenges arise in the validation and generalizability of routine data. There are substantial risks of bias in non-controlled interventional studies. In order to overcome these limitations and to improve the standing and quality of HRS in Germany, political opinion leaders and stakeholders need to be provided with continuous information on the need and potential of HRS. Methodological standards are needed for the evaluation of routine data, and principles of evidence-based medicine must be applied in all research addressing the effectiveness of health care interventions.     

Zur Bedeutung der Versorgungsforschung

In Germany, health services research has become an important area of research. Health services research is a multidisciplinary field of scientific investigation that studies central problems of health care to increase knowledge and understanding and provide solutions for those problems. The paper aims to demonstrate the value of health services research for health care practitioners by defining its central tasks, by describing the development of this research field in Germany and by deriving future challenges for health services researchers.     

Die geschichtliche Entwicklung der Intensivmedizin in Deutschland Folge 10: Medizinisch- methodische Entwicklung und Monitoring

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Scoring-Systeme in der Intensivmedizin

Scoring systems are used in all diagnostic areas of medicine. Several parameters are evaluated and rated with points according to their value in order to simplify a complex clinical situation with a score. The application ranges from the classification of disease severity through determining the number of staff for the intensive care unit (ICU) to the evaluation of new therapies under study conditions. Since the introduction of scoring systems in the 1980's a variety of different score models has been developed. The scoring systems that are employed in intensive care and are discussed in this article can be categorized into prognostic scores, expenses scores and disease-specific scores. Since the introduction of compulsory recording of two scoring systems for accounting in the German diagnosis-related groups (DRG) system, these tools have gained more importance for all intensive care physicians. Problems remain in the valid calculation of scores and interpretation of the results.     

Ethik in der Intensivmedizin

In more than 30 years of development of intensive care medicine (ICM), our speciality has acquired moral and ethical standpoints, although not without public pressure and discussions. Special commissions dealing, e.g., with brain death, terminal care, ethics of foregoing life-sustaining treatment in the critically ill, withholding or withdrawing mechanical ventilation, and other issues have meen formed in a number of medical societies. International consensus conferences have helped to clarify some of the issues. With increasing experience, a multitude of ethical problems have arisen in ICM that have to be dealt with, such as the issue of quality of life. What is an unworthy life? Are we allowed to make judgments for our patients? What is cost-effectiveness in ICM? Other restrictions include bed and equipment shortages in the intensive care unit (ICU), the necessity for triage – undisputed in catastrophe medicine – and how one should proceed in managing elective patients? In situations of limited ICU bed availability, sicker patients will be admitted, sparing out patients who are less ill for observation and those with poor quality of life and poor prognosis. For the future, it will likely be necessary to define the patients who should be admitted to an ICU more than those who should not be admitted. An ICU treatment entitlement index would be directly proportional to the probability of successful outcome and the quality of the remaining life, and would be inversely related to costs for achieving success. The ICU outcome with survival, hospital mortality, and follow-up of ICU patients is considered. DNR (do not resuscitate), the dying patient, terminal care, terminal weaning – DNT (do not treat) – active and passive euthanasia, living wills, quality of life, and cost-effectiveness for ICU patients are defined. Their application in the ICU will be discussed and problems pointed out. Outcome predictions using scores (APACHE III, SAPS II, MPM) have been developed based on previous experience, but should only be applied to patient groups and for quality assurance in ICUs. The most frequent and difficult problem in the ICU is the vegetative state, which requires an exact diagnosis. The differential diagnosis from other comatose states such as coma, brain death, and locked-in-syndrome is depicted. The ethics of interrupting life-sustaining treatment in critically ill patients have been worked out by a Task Force on Ethics of the Society of Critical Care Medicine (1990). A consensus was found that the patient may judge to forego therapy; ethically it is then appropriate to withhold or withdraw therapy. According to the consensus, withdrawing an already initiated treatment should not necessarily be regarded as more problematic than a decision not to initiate treatment. In my mind, however, there is a great difference between withdrawing or withholding, e.g., ventilation. A dissentive opinion by some members of the Task Force stated that hydration and nutrition other than high-technology or parenteral nutrition are key components of patient care, and should not be equated with medical intervention. The ethical problems associated with active euthanasia (physician-assisted suicide or death) as practised in the Netherlands are also discussed. In most countries this practice seems unacceptable. From 30 years experience in ICM, there are many more ethical questions and case reports without clear solutions. Care decisions for single patients in unacceptable situations should be made after medical evaluation by the intensivist with the medical team and, if possible, by the patient and/or his or her surrogate. Legislation and solutions cannot be expected for single patients, but ethics committees could be helpful in decision-making.     

Kolloide in der Intensivmedizin

Die Normovol?mie ist essentiell im Rahmen der Behandlung von Patienten w?hrend Narkose, in der Notfall- und Intensivmedizin. Grunds?tzlich stehen zur Volumensubstitution kristalloide L?sungen und kolloidale L?sungen zur Verfügung. In Europa ist die kombinierte Verwendung beider L?sungen anerkannter Standard. Differenzierte überlegungen zum Einsatz der verschiedenen Kolloide sind beim kritisch kranken Erwachsenen notwendig, da sowohl Humanalbumin als auch die künstlichen Kolloide Dextran, Gelatine und Hydroxyethylst?rke spezifische Effekte und typische Nebenwirkungen haben. Diese spielen unter den Gegebenheiten, die der Intensivpatient mit Organdysfunktionen und Organversagen aufweist, eine besondere Rolle. Die klinisch relevanten Daten zu allen Substanzen werden unter besonderer Berücksichtigung der Intensivmedizin diskutiert.

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Nierenprotektion in der Intensivmedizin

Background

Acute kidney injury (AKI) is a common and severe complication in patients on the intensive care unit with a significant impact on patient mortality, morbidity and costs of care; therefore, renal protective therapy is most important in these severely ill patients.

Aim of the review

Many renal protective strategies have been postulated during the last decades, which are sometimes still in place as a kind of “myth” but which are not always proven by evidence-based “facts”. The aim of this review is therefore to question and compare some of these “myths” with the available “facts”.

Recent findings

Most important for renal protection is the early identification of patients at risk for AKI or with acute kidney damage before renal function deteriorates further. A stage-based management of AKI comprises more general measures, such as discontinuation of nephrotoxic agents and adjustment of diuretic doses but most importantly early hemodynamic stabilization with crystalloid volume replacement solutions and vasopressors, such as noradrenaline. The aim is to ensure optimal renal perfusion and perfusion pressure. Patients with known arterial hypertension potentially need higher perfusion pressures. Large amounts of hyperchloremic solutions should be avoided. Volume overload and renal vasodilatory substances can also lead to further deterioration of kidney function. There is still no specific pharmacological therapy for renal protection.

     

Volumentherapie in der Intensivmedizin

Volume substitution represents an essential component of intensive care medicine. The amount of fluid administered, the composition and the timing of volume replacement seem to affect the morbidity and mortality of critically ill patients. Although restrictive volume strategies bear the risk of tissue hypoperfusion and tissue hypoxia in hemodynamically unstable patients liberal strategies favour the development of avoidable hypervolemia with edema and resultant organ dysfunction. However, neither strategy has shown a consistent benefit. In order to account for the heavily varying oxygen demand of critically ill patients, a goal-directed, demand-adapted volume strategy is proposed. Using this strategy, volume replacement should be aligned to the need to restore tissue perfusion and the evidence of volume responsiveness. As the efficiency of volume resuscitation for correction of tissue hypoxia is time-dependent, preload optimization should be completed in the very first hours. Whether colloids or crystalloids are more suitable for this purpose is still controversially discussed. Nevertheless, a temporally limited use of colloids during the initial stage of tissue hypoperfusion appears to represent a strategy which uses the greater volume effect during hypovolemia while minimizing the risks for adverse reactions.     

Krebspatienten in der operativen Intensivmedizin

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