COVID-19 and gastrointestinal endoscopy-proper strategies related to pandemic changes.

The outbreak of coronavirus disease 2019 (COVID-19) in December 2019 was associated with new challenges in many fields of medicine. Preventing transmission of the virus and infection of professional healthcare workers became of major concern in our daily clinical practice during the pandemic. Viral particles within aerosols can be detected up to 3h after aerosolization. Recent work defined endoscopic procedures of the upper gastrointestinal tract as being aerosol-generating procedures (AGPs);thus, they can carry the possibility of transmitting airborne viruses to personnel. Because severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) is primarily transmitted by aerosols and/or droplets, the use of personal protective equipment (PPE) is warranted. Guideline recommendations from the WHO and other societies were also modified early to include PPE as an infection prevention measure. The strict use of PPE has proven to be an effective prevention strategy over the 3 years since its implementation. With the introduction of vaccinations against SARS-CoV-2, increasing immunization of the population, and a changing pandemic infection pattern, the requirements for endoscopic departments in hospitals and outpatient care settings continued to change. In the postpandemic situation, there are only minor restrictions that affect the new "postpandemic reality", thus, allowing endoscopic services to be performed without major restrictions. Here, we present a review of recent and most relevant knowledge to summarize the prophylactic measures that must be taken to perform endoscopy under safe conditions during the COVID-19 pandemic.Copyright © 2023, The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.

COVID-19 and liver diseases.

In patients with coronavirus disease 2019 (COVID-19), hepatic involvement occurs in up to 53% of all cases. Via the primary target for severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2), the angiotensin-converting enzyme 2 (ACE2) receptor, expressed on cholangiocytes, sinusoidal endothelial cells, and hepatocytes, direct damage to the liver may occur. Furthermore, indirect (= not receptor-mediated) damage to the liver plays a crucial role in the context of COVID-19 due to severe systemic inflammation with cytokine storm, hepatic thrombosis, and systemic hypoxia. In COVID-19, liver enzymes are considered significant predictors of outcome. Thus, it is essential to rule out other causes of liver enzyme elevation, such as other viral infections, drug-induced liver injury, and metabolic, autoimmune and other liver diseases. Secondary sclerosing cholangitis in critically ill patients (SSC-CIP) is highly relevant in treating critically ill patients in the intensive care unit (ICU). Risk factors for SSC-CIP include high doses of catecholamines, high positive end-expiratory pressure (PEEP), and extracorporeal membrane oxygenation (ECMO) therapy. Early recognition of this disease and treatment by endoscopic retrograde cholangiography (ERC) is crucial. Furthermore, liver transplantation should be evaluated. Some patients with COVID-19 are diagnosed with SSC, which is termed COVID-19-associated SSC. COVID-19-associated SSC and SSC-CIP are comparable with regard to clinical phenotype, risk factors, prognosis, and graft-free survival. Patients with pre-existing liver disease are not at increased risk for infection with SARS-CoV-2 but show more severe clinical courses of COVID-19 than patients without pre-existing liver disease. Patients with pre-existing liver cirrhosis may develop acute-on-chronic liver failure (ACLF) upon infection with SARS-CoV-2. ACLF has a high mortality rate, which must be treated in the ICU.Copyright © 2023, The Author(s).

Interprofessional Collaboration between Physicians, Nurses, and Pharmacists Improves Medical and Economic Outcomes in an Intensive Care Unit with a Focus on Gastroenterology

Introduction: Since 2015, the medical intensive care unit (ICU) with a focus on gastroenterology of the Department of Internal Medicine 1 at the University Hospital Regensburg, Germany, has a particular emphasis on interprofessional collaboration with staff nurses and hospital pharmacists. The hospital pharmacists have access to the hospital information system and the electronic charting program. Consultations take place on daily basis. Furthermore, weekly joint rounds within the antibiotic stewardship program are performed. Furthermore, there is a joint training and teaching of medical, nursing and pharmacy students within the intensive care training ward Regensburg (I'M A-STAR project). Aims & Methods: The study aims to investigate to what extent the newly introduced structural changes affect clinical and economic outcomes. We examined clinical performance data and consumption figures for antibiotics and other drugs over a 10-year period from 2011 to 2021. Data from the hospital pharmacy, hospital administration, electronic charting, and hospital information systems were included in the analyses. An electronic platform was developed specifically to improve documentation. The years 2020 and 2021 were considered separately due to the COVID-19 pandemic and the care of numerous COVID-19 patients in the ICU. Result(s): It could be shown that the pharmacist's recommendations regarding drug administration were mainly related to indication (43.6%), dosage (27.6%), interactions (9.4%), and side effects (4.1%). Antibiotic consumption was reduced by 12.2% from 2015 to 2019. Encouragingly, this included a 23.4% reduction in carbapenem use. Antibiotic spending was reduced by 24.9% overall. An analysis of the intensive care G-DRGs showed that the case-mix points increased significantly by 31.6% during the period under review. Similarly, patient severity of illness as measured by the SAPS II score increased by 21.4%. The proportion of mechanically ventilated patients exceeded 50%. In another analysis, antibiotic spending per case-mix point was calculated. While spending was EUR 60.22 per case-mix point in 2015, this could be reduced by 42.9% to EUR 34.37 per case-mix point by 2019. Conclusion(s): Through close interprofessional collaboration between physicians, staff nurses, and pharmacists, the consumption of antibiotics and other drugs (e.g., albumin) was significantly reduced, thus improving patient care. There was also a positive economic effect - with a simultaneous increase in case-mix points, expenditure on antibiotics was significantly reduced. Responsible use of resources and high-performance medicine are not contradictory. In our view, a close interprofessional collaboration between physicians, staff nurses, and pharmacists will be of outstanding importance in the future, particularly in intensive care medicine.

[Geriatric patients in the intensive care unit]. / Der geriatrische Patient auf der Intensivstation.

The percentage of geriatric patients treated in intensive care units continues to increase, comprising up to 30%. Age per se is not of great relevance for the outcome of intensive care treatment. Functional status and geriatric syndromes are crucial for prognosis. Frailty and delirium are very important and should be screened using the Clinical Frailty Scale (CFS) and Confusion Assessment Method for the Intensive Care Unit (CAM-ICU), respectively. Furthermore, age-physiological organ changes as well as multimorbidity and associated polypharmacy play an important role. The latter should be assessed at the time of admission. Another goal of intensive care treatment of geriatric patients is to maintain and improve the nutritional status, which can be assessed with the help of an established tool (e.g. NRS 2002). In the treatment of critically ill geriatric patients with coronavirus disease 2019 (COVID-19), frailty is also crucial. It is particularly important in the intensive medical treatment of critically ill geriatric patients to clarify the question whether the patient benefits from each intensive care therapy, e.g., whether a desired therapeutic goal can be achieved, whether intensive care is in the (presumed) patient's will and whether the burdens during treatment are justified by the perspective of life. Furthermore, interdepartmental cooperation plays an important role in the intensive medical care of geriatric patients.