Medical Intensive Care Research Articles

Code Status Transitions in Patients with High-Risk Acute Myeloid Leukemia (AML)

Background:Patients with high-risk AML often experience intensive medical care at the end of life (EOL) such as hospitalization and intensive care unit (ICU) admission. Despite their poor prognosis, patients with AML and their caregivers often have substantial misperceptions of their prognosis, which may lead to difficult code status transitions near the end of life. However, studies examining code status transitions in patients with AML are lacking.Methods:We conducted a mixed-methods study of 200 patients with high-risk AML enrolled in supportive care studies at Massachusetts General Hospital between 2014-2021. High-risk AML was defined as: 1) new diagnosis ≥ 60 years, or 2) relapsed/refractory AML. Two physicians used consensus-driven medical record review to characterize code status transitions from time of diagnosis to death and identify patient, family, and palliative care involvement. Code status was coded as ‘full’ (confirmed or presumed), ‘restricted’ (i.e., do not resuscitate), or ‘comfort measures only’ (CMO). We used logistic regression to explore whether patient factors or features of the code status discussion were associated with the time between the last code status transition and death.Results:At diagnosis of high-risk AML, 86.0% of patients were ‘full code’ (38.5% presumed, 47.5% confirmed) and 8.5% had restrictions on life-sustaining therapies. Overall, 57% (114/200) of patients experienced a code status transition, with a median of two transitions (range 1-8) during their illness course. Overall, a total of 206 code status transitions were described across the cohort. Median time from diagnosis to first code status transition was 212 days (range 7-4507), and from last transition to death was 2 days (range 0-350). Most of these final code status transitions (71.1%, 81/114) were transitions to CMO near the end of life. Only 60.5% of patients (69/114) who underwent a code status transition participated in their last code status change. In contrast, patients and families participated in 87.7% (100/114) of the last code status transitions and palliative care was involved in 42.1% (48/114). A substantial minority of last code status transitions occurred in the ICU or emergency department (26.3%, 30/114). We identified three processes leading to code status transitions (Table 1): 1) pre-emptive conversations prior to any clinical change (15.6%, 32/206); 2) anticipatory conversations at the time of acute clinical deterioration (32.2%, 66/206); and 3) futility conversations after acute clinical deterioration, focused on withdrawing life-sustaining therapies (51.0%, 105/206). Older age (B = 0.07, P < 0.001), and receipt of non-intensive chemotherapy (B = 1.42, P = 0.003) were associated with a longer time from the last code status transition to death (Table 2). In contrast, futility conversations were associated with shorter time from last code status transition to death (B = -2.84, P < 0.001) compared to pre-emptive or anticipatory conversations.Conclusions:Almost half of patients were “presumed full code” at the time of diagnosis of high-risk AML and most experienced code status transitions at the end of life focused on futility of life-sustaining therapies after acute clinical deterioration. These results suggest that goals of care discussions occur too late in the typical illness course of patients with poor prognosis, high-risk AML. Interventions focused on enhancing patient engagement in timely discussions regarding their end of life care preferences are warranted. [Display omitted] DisclosuresLeBlanc: AbbVie: Consultancy, Honoraria, Other: Advisory board; Travel fees, Speakers Bureau; BMS/Celgene: Consultancy, Honoraria, Other: Travel fees, Research Funding, Speakers Bureau; Pfizer: Consultancy, Other: Advisory Board; Daiichi-Sankyo: Consultancy, Honoraria, Other: Advisory board; Flatiron: Consultancy, Other: Advisory board; Astellas: Consultancy, Honoraria, Other: Advisory board; American Cancer Society: Research Funding; Jazz Pharmaceuticals: Research Funding; AstraZeneca: Consultancy, Honoraria, Other: Advisory board, Research Funding; Agios: Consultancy, Honoraria, Other: Advisory board; Travel fees, Speakers Bureau; Duke University: Research Funding; Otsuka: Consultancy, Honoraria, Other; NINR/NIH: Research Funding; CareVive: Consultancy, Other, Research Funding; Helsinn: Consultancy, Research Funding; Heron: Consultancy, Honoraria, Other: advisory board; Amgen: Consultancy, Other: travel; UpToDate: Patents & Royalties; Seattle Genetics: Consultancy, Other: Advisory board, Research Funding.

Patient-Reported Benefits and Limitations of Mobile Health Technologies for Diabetes in Pregnancy: Protocol for a Scoping Review.

BackgroundFor women with pre-existing and gestational diabetes mellitus, pregnancy involves specialized and intensive medical care to improve maternal and infant outcomes. Medical management for patients with diabetes in pregnancy typically occurs via frequent face-to-face outpatient appointments. Barriers to face-to-face care during the COVID-19 pandemic have signaled the need for high-quality, patient-centered virtual health care modalities, such as mobile health (mHealth).ObjectiveThe objective of the proposed scoping review is to identify the patient-reported benefits and limitations of mHealth technology among women with diabetes in pregnancy. We also aim to determine how the women’s experiences align with the best practice standards for patient-centered communication.MethodsArksey and O’Malley’s framework for conducting scoping reviews with refinements by Levac et al will be used to guide the conduct of this scoping review. Relevant studies will be identified through comprehensive database searches of MEDLINE, Embase, Emcare, and PsycINFO. Following database searches, studies will be screened for eligibility at the title, abstract, and full-text level by two independent reviewers, with the inclusion of a third reviewer if required to reach consensus. Data charting of included studies will be conducted by one reviewer using a standardized data extraction form and verified independently by a second reviewer. Synthesis of results will be guided by Thomas and Harden’s “Methods for the Thematic Synthesis of Qualitative Research in Systematic Reviews.”ResultsAs of August 2020, we have carried out the qualitative searches in the electronic databases MEDLINE, Embase, Emcare, and PsycINFO (Ovid interface) for a combined total of 8207 articles. Next, we plan to conduct the quantitative searches in the electronic databases MEDLINE, Embase, and Emcare (Ovid interface). We also plan to review the reference lists of relevant studies to identify additional eligible studies.ConclusionsWith the results of this review, we hope to describe the patient-reported benefits and limitations of mHealth technology for women with diabetes in pregnancy. Furthermore, we aim to determine how women’s experiences align with the best practice standards for patient-centered communication. Ultimately, our review can provide valuable information for guideline developers, policy makers, and clinicians related to mobile technologies to support virtual care delivery for women with diabetes in pregnancy.International Registered Report Identifier (IRRID)PRR1-10.2196/29727

Focus on nephrology : Intensive medical care studies 2020/2021

Focus on nephrology : Intensive medical care studies 2020/2021

Congenital Nasolacrimal Duct Obstruction Update Study (CUP Study): Paper 4-Infantile Acute Dacryocystitis (InAD)-Presentation, Management, and Outcomes.

To study the presentation, management, and outcomes of infantile acute dacryocystitis. Retrospective study of infants diagnosed with acute dacryocystitis over a period from June 2016 to December 2019. Data collected include demographics, clinical history, presenting features, management, complications, and outcomes. Treatment provided was intensive medical care followed by early probing under endoscopic guidance. Further interventions, where needed, were performed based on intraoperative findings during probing. Successful outcomes were defined as resolution of infection, subjective relief from epiphora, and anatomical patency determined by a normal fluorescein dye disappearance test. Twenty-seven eyes of 27 infants were analyzed during the study period. The mean age of infants was 3.26 months, and males were more affected than females (male:female 15:12). The mean duration of symptoms was 4.66 weeks, with 96% (26/27) presenting with symptoms of redness, watering, discharge, and swelling. Preseptal cellulitis was seen in 74% (20/27) infants, lacrimal abscess in 67% (18/27) infants, and lacrimal fistula in 37% (10/27). Most infants had complex congenital nasolacrimal duct obstruction (62%, 13/27), of which 7 also had intranasal cysts. One infant successfully underwent endoscopic dacryocystorhinostomy. At a mean follow-up period of 7.95 months, successful outcomes were observed in 90.4% (19/21) infants. The 2 failed cases were complex congenital nasolacrimal duct obstruction with associated sac diverticula and are scheduled for an endoscopic dacryocystorhinostomy. Infantile acute dacryocystitis is a distinct clinical entity. The outcomes of systemic antibiotics and early probing are excellent.

An outbreak investigation of Burkholderia cepacia infections related with contaminated chlorhexidine mouthwash solution in a tertiary care center in Turkey

BackgroundWe report a nosocomial outbreak caused by Burkholderia cepacia that occurred among six patients admitted in the medical and surgical intensive care unit between 04 March 2019 and 02 April 2019 in Istanbul, Turkey.MethodsThe outbreak investigation was launched on 11 March 2019 five days after the detection of B. cepacia in four different patients. We defined potential reservoirs and started environmental screening. We sampled the liquid solutions used in patient care activities. Pulse-field gel electrophoresis (PFGE) was performed to determine the genetic relatedness of environmental and patient samples.ResultsBurkholderia cepacia was isolated in tracheal aspiration cultures of six patients. Three out of six patients developed healthcare-associated pneumoniae due to B. cepacia. Environmental cultures in the ICUs revealed B. cepacia growth in 2% chlorhexidine-gluconate mouthwash solution that been used in the colonized patients as well as in samples obtained from the unused products. PFGE revealed the patient and a specific batch of chlorhexidine mouthwash solution samples had a 96% similarity.ConclusionContamination of medical solutions used in critical patient care could cause outbreaks and should be detected early by infection control teams.Graphic abstract

Focus ventilation, oxygen therapy and weaning : Intensive medical care studies from 2020/2021

Focus ventilation, oxygen therapy and weaning : Intensive medical care studies from 2020/2021

Functional assessment and rehabilitation protocol in acute patients affected by SARS-CoV-2 infection hospitalized in the Intensive Care Unit and in the Medical Care Unit.

Coronavirus disease (COVID-19) is characterized by different clinical pictures that may require prolonged hospitalization and produce disabilities challenging the recovery of previous independence. The aim is to evaluate the impact of an early assisted rehabilitation program on the functional status of an acutely hospitalized population affected by COVID-19. Single-institution retrospective longitudinal study. Inpatient intensive care units (ICU) and medical care units (MCU). Acute COVID-19 patients. General information was collected; age-adjusted Charlson Comorbidity Index was used for comorbidities. Duration of hospital stay, the length of stay in ICU and/or MCU, the length of the rehabilitative treatment, and the destination at the discharge were collected. Evaluation was performed when patients were clinically stable (T0), and at hospital discharge (T1); for subjects enrolled in ICU functional status was assessed at the time of transfer to the MCU. Muscle strength of the four limbs was measured with the Medical Research Council (MRC) sum-score. Functional status was assessed using the 3-item Barthel Index (BI-3) and the General Physical Mobility Score (GPMS). Early assisted-tailored rehabilitation protocol was applied in ICU and in MCU: the aims were the maintenance (or recovery) of the range of motion and of the strength and the recovery of sitting/standing position and gait. We evaluated 116 patients (mean age 65, SD 11) (65% male), 68 in ICU (mean age 60, SD 10), 48 in MCU (mean age 73, SD 9). At discharge, BI-3 and GPMS significantly improved in both ICU (P<0.001) and MCU (P<0.001) subgroups of patients. MRC sum-score significantly improved in ICU patients (P<0.001). Patients hospitalized in ICU had a significantly longer hospital stay. At discharge, patients admitted to the ICU reach a functional state that is close to that of patients admitted to the MCU. The results suggest that an early assisted rehabilitation program may be helpful in improving the short-term functional status of an acutely hospitalized population affected by COVID-19, with discharge at home of 48% CLINICAL REHABILITATION IMPACT: this study focuses on a functional assessment method to be used to identify the rehabilitation needs and verify the results of an early rehabilitation protocol applied to the acute COVID-19 patient admitted to ICU and MCU.

Critical care challenges in the orthopedic patients: A study

Aim: The purpose of this study is to evaluate the causes, numbers, outcomes of Orthopedic patients requiring intensive care. Methods: A retrospective and prospective study of patients admitted as in patients, under orthopaedic care, in PGSIMSR, and who required intensive medical care were included in this study. Conclusion: With increasing trauma and polytrauma cases, coupled with increasing geriatric population, intensive care has becoming more and more common in orthopaedic patients. Mortality rate is higher in the trauma group. Elderly patients are more likely to develop complications due to associated comorbidities. This emphasizes the importance of pre operative and postoperative monitoring of these vulnerable patients.

34.3 CHRONIC MANIFESTATIONS AND PROLONGED ILLNESS FROM COVID-19 IN CHILDREN

Although children are less likely to be infected with the SARS-CoV-2 virus, a small subset of children develop serious acute illness, namely multisystem inflammatory syndrome in children (MISC). Acute MISC can cause severe disease requiring intensive medical care, and little is known about the long-term outcomes of acute MISC. Given what is known about similar inflammatory syndromes, serious COVID-19 illness is likely to have lasting effects on multiple body systems. In adults, it is estimated that approximately 10% of persons infected with COVID-19 develop a “long haul” illness, and emerging case reports highlight similar prolonged illness in adolescents.

Do fluorocarbons substantially increase transdermal oxygen delivery? A proof-of-principle study in mice

Background: Coronavirus disease 2019 (COVID-19) patients who need intensive medical care often require oxygen ventilation, but the number of ventilation machines is limited, and in some parts of the world, they are not available at all. In addition to patients for whom there is no access to ventilation machines there is also a considerable population of patients for whom ventilation is not sufficient for them to survive a critical state. Methods: Here, we propose and test an alternative oxygen supply through accelerated transdermal oxygen delivery. Covering the entire body with liquid fluorocarbons, which can dissolve 20 times more oxygen than water, we hypothesized to increase the contribution of transcutaneous respiration by a sustained amount. Results: Experiments applying pure medical grade perfluorodecalin on nude mice did not change their oxygenation in the blood under induced hypoxic conditions compared to control mice. However, increases in blood oxygenation below 2% could not be detected with the applied method. Conclusions: We could not establish a proof-of-principle for a substantial increase in oxygen supply by transdermal oxygen delivery in mammals.

Острые отравления токсическими газами на производстве (лекция)

В лекции представлены ведущие механизмы поражения организма, типичная клиническая картина и принципы оказания экстренной медицинской помощи (ЭМП) и интенсивной терапии пострадавшим с острыми отравлениями токсическими газами. В связи с тем, что риск одновременного появления большого количества пострадавших с указанными отравлениями всегда велик именно в условиях химического производства, вопросы оказания ЭМП этому контингенту больных всегда актуальны. В лекции рассматриваются особенности поражения организма человека аммиаком, хлором, сероводородом, арсином, окислами азота, формальдегидом, монооксидом углерода и парами бензина. Все эти химические соединения являются широко распространенными химическими реагентами и промежуточными продуктами химических реакций на производстве. Ингаляционный путь попадания летучих веществ в организм определяет ускоренное развитие клинической симптоматики вследствие быстрого поступления токсичных химических соединений в кровь пострадавших. Расстройства в функционировании системы внешнего дыхания являются одними из наиболее распространенных при вдыхании таких агрессивных химических соединений, как аммиак, хлор, окислы азота, формальдегид, пары бензина. Поступление в организм угарного газа, окислов азота и сероводорода обусловливает высокий риск образования гемической гипоксии и связанных с ней поражений центральной нервной и сердечно-сосудистой системы. Вдыхание таких соединений, как сероводород, арсин, формальдегид, окись углерода, определяет развитие нарушений функционирования тканевого дыхания. Практически все химические соединения, действие которых представлено в лекции, способны оказывать общий токсический эффект на организм пострадавших. При освещении аспектов предоставления ЭМП подчеркивается потребность в немедленном прекращении контакта пациентов с токсическим веществом, профилактике и интенсивной терапии синдрома острой дыхательной недостаточности, применении антидотов и препаратов с противогипоксическим эффектом, которые улучшают процессы тканевого дыхания и способствуют росту выработки энергии.

Prospective Study on Risk Factors of Ventilator-associated Pneumonia in Intensive Medical Care

Prospective Study on Risk Factors of Ventilator-associated Pneumonia in Intensive Medical Care

Embracing cancer immunotherapy with vital micronutrients.

Immunotherapy is now commonly prescribed to cancer patients, but autoimmune-related adverse events are considerable. For severe, life-threatening side effects, cessation of therapy seems unavoidable, let alone intensive medical care required for patching up the adverse events. Even without serious adverse events, the response rates are too low and various combinatory regimens have been tried. However, toxicities are also added on, unless the adjuvant agents have remarkably few side effects. Actually, micronutrients are usually taken by a majority of cancer patients as nutritional support or to boost the immune function, let alone hoping to counteract treatment side effects. Recent studies have shown that combinations of micronutrients exert pleiotropic effects in controlling tumor growth and metastasis by modulating the tumor microenvironment, enhancing gut microbiota immune functions, and providing adjunct nutritional support to micronutrient deficient cancer patients. A higher than recommended dietary allowance micronutrient dose is proposed to reduce the toxic free radicals generated as a result of immunotherapy and tumor metabolism. This is not only helpful for managing treatment side effects but also enhancing treatment efficacy. As micronutrient supplementation is also useful to improve patients’ quality of life, prolong survival, and sustain compliance to immunotherapy, further investigations are mandatory.

Disease Severity and Prognosis of SARS-CoV-2 Infection in Hospitalized Patients Is Not Associated With Viral Load in Nasopharyngeal Swab.

Background: The impact of viral burden on severity and prognosis of patients hospitalized for Coronavirus Disease 2019 (COVID-19) is still a matter of debate due to controversial results. Herein, we sought to assess viral load in the nasopharyngeal swab and its association with severity score indexes and prognostic parameters.Methods: We included 127 symptomatic patients and 21 asymptomatic subjects with a diagnosis of SARS-CoV-2 infection obtained by reverse transcription polymerase chain reaction and presence of cycle threshold. According to the level of care needed during hospitalization, the population was categorized as high-intensity (HIMC, n = 76) or low intensity medical care setting (LIMC, n = 51).Results: Viral load did not differ among asymptomatic, LIMC, and HIMC SARS-CoV-2 positive patients [4.4 (2.9–5.3) vs. 4.8 (3.6–6.1) vs. 4.6 (3.9–5.7) log10 copies/ml, respectively; p = 0.31]. Similar results were observed when asymptomatic individuals were compared to hospitalized patients [4.4 (2.9–5.3) vs. 4.68 (3.8–5.9) log10 copies/ml; p = 0.13]. When the study population was divided in High (HVL, n = 64) and Low Viral Load (LVL, n = 63) group no differences were observed in disease severity at diagnosis. Furthermore, LVL and HVL groups did not differ with regard to duration of hospital stay, number of bacterial co-infections, need for high-intensity medical care and number of deaths. The viral load was not an independent risk factor for HIMC in an adjusted multivariate regression model (OR: 1.59; 95% CI: 0.46–5.55, p = 0.46).Conclusions: Viral load at diagnosis is similar in asymptomatic and hospitalized patients and is not associated with either worse outcomes during hospitalization. SARS CoV-2 viral load might not be the right tool to assist clinicians in risk-stratifying hospitalized patients.

Acute appendicitis in children during the COVID-19 pandemic

Introduction. Ear complications in children are rare and are still an immediate life threatening condition. In children the most common complication is acute mastoiditis in the course of acute otitis media. The predominant symptoms are severe pain in the ear and the retroauricular region, swelling of the muzzle region with protrusion of the auricle and subsidence of the posteriori-top wall of the external auditory canal. Aim. The aim of this study was to present patients with acute mastoiditis during the COVID-19 pandemic and to evaluate the co-infection with SARS-CoV-2 virus. Material and methods. A retrospective analysis of hospitalized patients with acute mastoiditis between 2020 and 2021 was performed. We evaluated the co-occurrence of SARS-CoV-2 infection in children with ear complications, seasonality of complications, age, gender, diagnostic methods and analysis of pathogens responsible for the development of the complication. Results. Between 2020 and 2021, 23 patients with acute mastoiditis were hospitalized at the Department of Pediatric Otolaryngology University Clinical Center Medical University of Warsaw. One patient was diagnosed with coexisting SARS-CoV-2 infection. In the analyzed group there was a significant predominance of boys over girls M:K = 2.8:1. The mean age of the patients was 5 years. All patients showed clinical signs of acute mastoiditis in the form of swelling of the soft tissues of the behind-the-ear region with inflammation of the skin and withdrawal of the auricle. Otoscopic examination revealed purulent middle ear leakage in 22% of children, while the remaining 78% showed no perforation of the tympanic membrane, with purulent discharge deposited throughout the tympanic cavity. In the bacteriological studies obtained, no pathogens were found in 74% of the children. All patients had intravenous antibiotic therapy and surgical treatment. Conclusions. Among hospitalized patients with acute mastoiditis, the highest morbidity was observed in January-April 2020 and September-December 2021. No patient with ear complication was hospitalized from May 2020 to September 2020. This was the period when, from May 2020, day nurseries, kindergartens and schools began to be subject to strict sanitary regime recommendations by the Chief Sanitary Inspectorate, which could contribute to a reduced incidence of upper respiratory tract infections. Hospitalization of a patient with acute mastoiditis with a coexisting complication of SARS-CoV-2 infection required isolation of the patient in the observation-isolation unit of our hospital. However, the patient’s respiratory and circulatory distress wasn’t observed and he didn’t require intensive medical care.

Clinical Experience, Characteristics, and Performance of an Acetaminophen Absorption Test in Critically Ill Patients.

Altered drug and nutrient absorption presents a unique challenge in critically ill patients. Performing an acetaminophen absorption test (AAT) has been used as a marker for gastric motility and upper small bowel absorption; thus, it may provide objective data regarding enteral absorptive ability in critically ill patients. What is the clinical experience with AAT when used as a surrogate marker for enteral absorption in critically ill patients? This single-center, retrospective, cohort study evaluated serum acetaminophen concentrations within 180 minutes following 1-time enteral administration of an AAT. Patients admitted to the surgical and medical intensive care units and medical intensive care units over a 7-year period were evaluated. Groups were defined as positive (acetaminophen concentration of ≥10 mg/L) or negative (acetaminophen concentration of <10 mg/L) AAT. The outcomes were to describe the clinical experience, characteristics, and performance of AAT. Forty-eight patients were included. Patients were 58.5 ± 14 years of age, mostly male (58.3%), and admitted to the surgical intensive care unit (66.7%). Median hospital length of stay was 47.5 (27-78.8) days. Thirty-four patients (70.8%) had a positive AAT [median concentration, 14 (12-18) mg/L]. Median time to first detectable concentration was 37 (33-64) minutes. AAT characteristics were similar between the groups including total dose, weight-based dose, time to first and second assays, drug formulation, and site of administration between groups. There were no independent risk factors identified on regression analysis for negative AAT. An acetaminophen dose of 15 mg/kg with 2 coordinated serum concentrations approximately 30 and 60 minutes after administration is a reasonable construct for AAT. Future research is needed to assess AAT utility, safety, and clinical outcomes for predicting patient ability to absorb enteral feeds and medications.

Neurosurgical intensive care medicine : Intensive medical care studies from 2020/2021

Neurosurgical intensive care medicine : Intensive medical care studies from 2020/2021

Safe Return to Exercise after COVID-19 Infection.

COVID-19 has been posing a significant challenge to the athletic community. A wide spectrum of clinical features was reported in athletes with confirmed COVID-19 infection having mild to severe symptoms requiring hospitalisation and intensive medical care. Possibly, a lack of exercise may negatively impact the immune system, leading to an increased susceptibility to infection and comorbidities. Determining safe return to exercise after COVID-19 infection is a challenge for sports physicians. A gradual return to exercise under the guidance of a specialised medical team to achieve the pre-infection fitness level is of utmost importance. Individualised exercise programmes must be initiated at low intensity which could be gradually made more rigorous based on the pertinent metabolic equivalent. Thus, there is a clear need for clinical recommendations before athletes may return to exercise after COVID-19 infection.

Geriatric patients in the intensive care unit

Der Anteil geriatrischer Patienten auf der Intensivstation an allen dort behandelten Patienten beträgt bis zu 30 %. Das Alter per se ist jedoch kein Prognosekriterium für das therapeutische Outcome einer intensivmedizinischen Behandlung. Prognostisch wichtiger sind der funktionelle Status und geriatrische Syndrome. Hierbei sind die Gebrechlichkeit (Frailty) und das Delir von zentraler Bedeutung. Zum jeweiligen Screening sollten Clinical Frailty Scale (CFS) bzw. Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) zur Anwendung kommen. Darüber hinaus spielen altersphysiologische Organveränderungen sowie Multimorbidität und die damit assoziierte Polypharmazie eine wichtige Rolle. Letztere sollte bereits bei Aufnahme auf ihre absolute Notwendigkeit hin überprüft werden. Ein weiteres Ziel der intensivmedizinischen Behandlung von geriatrischen Patienten ist die Erhaltung und Verbesserung ihres Ernährungszustands. Zu seiner Erfassung sollte ein Screening mithilfe eines etablierten Tools (z. B. Nutritional Risk Screening [NRS] 2002) erfolgen. Bei der Behandlung von kritisch kranken geriatrischen Patienten mit Coronoaviruserkrankung 2019 (COVID-19) hat die Gebrechlichkeit ebenfalls eine entscheidende Bedeutung. Grundsätzlich ist bei jeder Therapieanwendung gerade auch bei geriatrischen Patienten die Frage nach der Sinnhaftigkeit der intensivmedizinischen Behandlung unter Beachtung des (mutmaßlichen) Patientenwillens und seiner Lebensperspektive zu klären. Dabei ist zu prüfen, ob ein angestrebtes Therapieziel erreicht werden kann und ob die Belastungen während der Behandlung gerechtfertigt ist. Weiterhin spielt bei der intensivmedizinischen Versorgung geriatrischer Patienten die sektorenübergreifende Zusammenarbeit eine wichtige Rolle.

Clinical ethics case consultation in a university department of cardiology and intensive care: a descriptive evaluation of consultation protocols

BackgroundClinical ethics case consultations (CECCs) provide a structured approach in situations of ethical uncertainty or conflicts. There have been increasing calls in recent years to assess the quality of CECCs by means of empirical research. This study provides detailed data of a descriptive quantitative and qualitative evaluation of a CECC service in a department of cardiology and intensive care at a German university hospital.MethodsSemi-structured document analysis of CECCs was conducted in the period of November 1, 2018, to May 31, 2020. All documents were analysed by two researchers independently.ResultsTwenty-four CECCs were requested within the study period, of which most (n = 22; 92%) had been initiated by physicians of the department. The patients were an average of 79 years old (R: 43–96), and 14 (58%) patients were female. The median length of stay prior to request was 12.5 days (R: 1–65 days). The most frequent diagnoses (several diagnoses possible) were cardiology-related (n = 29), followed by sepsis (n = 11) and cancer (n = 6). Twenty patients lacked decisional capacity. The main reason for a CECC request was uncertainty about the balancing of potential benefit and harm related to the medically indicated treatment (n = 18). Further reasons included differing views regarding the best individual treatment option between health professionals and patients (n = 3) or between different team members (n = 3). Consensus between participants could be reached in 18 (75%) consultations. The implementation of a disease specific treatment intervention was recommended in five cases. Palliative care and limitation of further disease specific interventions was recommended in 12 cases.ConclusionsTo the best of our knowledge, this is the first in-depth evaluation of a CECC service set up for an academic department of cardiology and intensive medical care. Patient characteristics and the issues deliberated during CECC provide a starting point for the development and testing of more tailored clinical ethics support services and research on CECC outcomes.