Critical Care Providers' Moral Distress: Frequency, Burden, and Potential Resources.

BACKGROUND: Critical Care Providers (CCPs) experience situations that challenge their ethics and professional standards and may entail moral distress (MD). AIM: To analyze MD perceived by CCPs in intensive care units (ICUs) or emergency departments (EDs) and further clarify whether CCPs who rely on spiritual resources differ in their perception of MD from those who do not utilize these resources. METHODS: A cross-sectional anonymous survey was administered using a modified version of the German language version of the Moral Distress Scale (MDS) with 2 × 12 items to assess the frequency and the respective perceived burden of specific situations by applying a 5-point Likert scale. Explorative factor analysis was performed and the sub-constructs of the respective items regarding MD frequency and burden were identified. Job burden and professional satisfaction were measured using visual analogue scales (VAS) and a four-point Likert scale, respectively. The 15-item SpREUK questionnaire was applied to measure spiritual attitudes and behaviours and to differentiate between religious and spiritual persons. Data from 385 German-speaking CCPs were included (55% physicians, 45% nurses). RESULTS: Conflict situations are similar for physicians and nurses although they are perceived as more burdensome by nurses. Among physicians, the MDS factor Looking away/Resignation scores highest for assistant physician residents, whereas distress caused by looking away is more often perceived by specialist physicians without a managerial position. Work satisfaction is inversely associated with MD and emotional exhaustion is positively associated with it. Participants' spirituality is marginally associated with MD. The best predictors of both MD frequency and burden are emotional exhaustion with further influences of work satisfaction, being a nurse, and being a non-believer on the frequency of MD perception. Being a nurse, participants' experience in ICU/ED, and being of the male gender are further predictors of MD burden. CONCLUSIONS: MD is experienced differently by different groups of CCPs depending on their place in the hierarchy of responsibility. As MD perception is best predicted by emotional exhaustion, these situations should be avoided. Although some CCPs may rely on spiritual resources, all need individual and team support to cope with MD.

[ECMO support during the first two waves of the corona pandemic-a survey of high case volume centers in Germany]. / ECMO-Unterstützung während der ersten 2 Wellen der Coronapandemie ­ eine Umfrage an Zentren mit hohen Fallzahlen in Deutschland.

BACKGROUND: At the onset of the coronavirus pandemic, concerns were raised about sufficiency of available intensive care resources. In many places, routine interventions were postponed and criteria for the allocation of scarce resources were formulated. In Germany, some hospitals were at times seriously burdened during the course of the pandemic. Intensive care units in particular experienced a shortage of resources, which may have led to a restriction of services and a stricter indication setting for resource-intensive measures such as extracorporeal membrane oxygenation (ECMO). The aim of this work is to provide an overview of how these pressures were managed at large ECMO centers in Germany. METHODS: One representative of each major ECMO referral center in Germany was invited to participate in an online survey in spring 2021. RESULTS: Of 34 invitations that were sent out, the survey was answered by 23 participants. In all centers, routine procedures were postponed during the pandemic. Half of the centers increased the number of beds on which ECMO procedures could be offered. Nevertheless, in one-third of the centers, the start of at least one ECMO support was delayed because of a feared resource shortage. In 17% of centers, at least one patient was denied ECMO that he or she would have most likely received under prepandemic conditions. CONCLUSION: The results of this online survey indicate that the experienced pressures and resource constraints led some centers to be cautious about ECMO indications.

Cumulative Incidence of SARS-CoV-2 in Healthcare Workers at a General Hospital in Germany during the Pandemic-A Longitudinal Analysis.

Health workers (HW) are at increased risk for SARS-CoV-2 infection. In order to monitor the infection dynamic on the basis of contact with patients, HW at the St. Antonius Hospital (SAH) were tested four times in one year by PCR and serology. The cumulative incidence of infection in HW was calculated. Swab and blood tests were simultaneously performed between April 2020 and April 2021. Risk factors and demographic information were assessed at the beginning of the study. The response rate was above 75% in all rounds of testing. The study comprised 1506 HW, 165 (10.6%) of which tested positive for SARS-CoV-2 infection. Working in an ICU or on wards with patient contact were risk factors (OR 4.4, 95% CI 1.73-13.6 and OR 2.9, 95% CI 1.27-8.49). At the end of the study, the majority of HW (810 of 1363 (59.4%)) had been vaccinated at least once. A total of 29.1% of unvaccinated HW and 5.3% of vaccinated HW showed an immune response typical for natural SARS-CoV-2 infection. Of the 73 HW who provided information on the course of the disease, 31.5% reported that their quality of life continued to be impaired. The cumulative incidence of infection was low in these HW, which may be attributed to vaccination and good hygiene. Nevertheless, a work-related infection risk was identified, highlighting the need to improve protection against infection. A high risk of developing long COVID was found after the infection has subsided. Special rehabilitation programs should be provided and HW should be compensated for reduced work capacity in the case that rehabilitation fails or takes a long time.

[Maternity protection-also during the corona crisis]. / Mutterschutz ­ auch im Zeitalter der Coronakrise.

Pregnant employees should be protected, particularly in crisis situations. The Maternity Protection Act states that employees are not allowed to have contact with infectious people, including people with SARS-CoV-2 infections; no new regulation is required here.

The SARS-CoV-2/Receptor Axis in Heart and Blood Vessels: A Crisp Update on COVID-19 Disease with Cardiovascular Complications.

The SARS-CoV-2 virus causing COVID-19 disease has emerged expeditiously in the world and has been declared pandemic since March 2020, by World Health Organization (WHO). The destructive effects of SARS-CoV-2 infection are increased among the patients with pre-existing chronic conditions and, in particular, this review focuses on patients with underlying cardiovascular complications. The expression pattern and potential functions of SARS-CoV-2 binding receptors and the attributes of SARS-CoV-2 virus tropism in a physio-pathological state of heart and blood vessel are precisely described. Of note, the atheroprotective role of ACE2 receptors is reviewed. A detailed description of the possible detrimental role of SARS-CoV-2 infection in terms of vascular leakage, including endothelial glycocalyx dysfunction and bradykinin 1 receptor stimulation is concisely stated. Furthermore, the potential molecular mechanisms underlying SARS-CoV-2 induced clot formation in association with host defense components, including activation of FXIIa, complements and platelets, endothelial dysfunction, immune cell responses with cytokine-mediated action are well elaborated. Moreover, a brief clinical update on patient with COVID-19 disease with underlying cardiovascular complications and those who had new onset of cardiovascular complications post-COVID-19 disease was also discussed. Taken together, this review provides an overview of the mechanistic aspects of SARS-CoV-2 induced devastating effects, in vital organs such as the heart and vessels.

Conservative management of COVID-19 associated hypoxaemia.

This correspondence argues that data presented previously cannot justify a novel approach for treating hypoxic patients with severe #COVID19 https://bit.ly/3dLaPlk.

Outcome Prediction in Patients with Severe COVID-19 Requiring Extracorporeal Membrane Oxygenation-A Retrospective International Multicenter Study.

The role of veno-venous extracorporeal membrane oxygenation therapy (V-V ECMO) in severe COVID-19 acute respiratory distress syndrome (ARDS) is still under debate and conclusive data from large cohorts are scarce. Furthermore, criteria for the selection of patients that benefit most from this highly invasive and resource-demanding therapy are yet to be defined. In this study, we assess survival in an international multicenter cohort of COVID-19 patients treated with V-V ECMO and evaluate the performance of several clinical scores to predict 30-day survival. METHODS: This is an investigator-initiated retrospective non-interventional international multicenter registry study (NCT04405973, first registered 28 May 2020). In 127 patients treated with V-V ECMO at 15 centers in Germany, Switzerland, Italy, Belgium, and the United States, we calculated the Sequential Organ Failure Assessment (SOFA) Score, Simplified Acute Physiology Score II (SAPS II), Acute Physiology And Chronic Health Evaluation II (APACHE II) Score, Respiratory Extracorporeal Membrane Oxygenation Survival Prediction (RESP) Score, Predicting Death for Severe ARDS on V­V ECMO (PRESERVE) Score, and 30-day survival. RESULTS: In our study cohort which enrolled 127 patients, overall 30-day survival was 54%. Median SOFA, SAPS II, APACHE II, RESP, and PRESERVE were 9, 36, 17, 1, and 4, respectively. The prognostic accuracy for all these scores (area under the receiver operating characteristic-AUROC) ranged between 0.548 and 0.605. CONCLUSIONS: The use of scores for the prediction of mortality cannot be recommended for treatment decisions in severe COVID-19 ARDS undergoing V-V ECMO; nevertheless, scoring results below or above a specific cut-off value may be considered as an additional tool in the evaluation of prognosis. Survival rates in this cohort of COVID-19 patients treated with V­V ECMO were slightly lower than those reported in non-COVID-19 ARDS patients treated with V-V ECMO.

[Prevalence of SARS-CoV-2 in employees of a general hospital in Northrhine-Westphalia, Germany]. / Prävalenz von SARS-CoV-2 bei Mitarbeitern eines Krankenhauses der Regel-/Schwerpunktversorgung in Nordrhein-Westfalen.

BACKGROUND: We assessed the prevalence of SARS-CoV-2 in the staff of a general hospital in North-Rhine-Westphalia in a cross-sectional study. METHOD: Employees (n = 1363) were offered a nasopharyngeal swab and serology for SARS-CoV-2. Additionally, employees completed a questionnaire about preexisting conditions, contacts with SARS-CoV-2-positive individuals and COVID-19-specific symptoms. RESULTS: 1212 employees participated. 19 of 1363 (1.4 %) employees tested positive by PCR (3 within and 16 before the study). 40 (3.3 %) and 105 (8.6 %) had IgG and IgA, respectively, 32 (2.6 %) both IgG and IgA. Overall, 47 employees tested positive. In this group, most frequently reported symptoms were headache (56 %), fatigue (49 %), sore throat (49 %), and cough (46 %); fever was reported by 33 %. SARS-CoV-2-positive employees reported more frequently contact with COVID-19 cases (60.5 % vs. 37.3 %, p = 0.006). Employees testing positive only for IgA reported less symptoms. CONCLUSION: Between 27.04. and 20.05.2020, 3.9 % of the employees working in a general hospital were tested positive for SARS-CoV-2. This proportion was lower than expected; possible explanations are the low level of endemic infection and the extensive, uniform in-house preventative measures.

Decisions on the allocation of intensive care resources in the context of the COVID-19 pandemic : Clinical and ethical recommendations of DIVI, DGINA, DGAI, DGIIN, DGNI, DGP, DGP and AEM.

In view of the globally evolving coronavirus disease (COVID-19) pandemic, German hospitals rapidly expanded their intensive care capacities. However, it is possible that even with an optimal use of the increased resources, these will not suffice for all patients in need. Therefore, recommendations for the allocation of intensive care resources in the context of the COVID-19 pandemic have been developed by a multidisciplinary group of authors with the support of eight scientific medical societies. The recommendations for procedures and criteria for prioritisations in case of resource scarcity are based on scientific evidence, ethicolegal considerations and practical experience. Medical decisions must always be based on the need and the treatment preferences of the individual patient. In addition to this patient-centred approach, prioritisations in case of resource scarcity require a supraindividual perspective. In such situations, prioritisations should be based on the criterion of clinical prospect of success in order to minimize the number of preventable deaths due to resource scarcity and to avoid discrimination based on age, disabilities or social factors. The assessment of the clinical prospect of success should take into account the severity of the current illness, severe comorbidities and the patient's general health status prior to the current illness.

[German recommendations on lung and thoracic ultrasonography in patients with COVID-19]. / Empfehlungen zur Lungen- und Thoraxsonographie bei Patienten mit COVID-19-Erkrankung.

Lung and chest ultrasound are further examination modalities in addition to computed tomography and laboratory diagnostics in patients with COVID-19. It extends the clinical-physical examination because it can examine lung surface sensitively. Lung surface pattern changes have been found in sonograms of patients with COVID-19 pneumonia and during the course of the disease. German specialist societies of clinical acute, emergency and intensive care medicine as well as imaging, which are concerned with the care of patients with SARS-CoV­2 infection and COVID-19, have coordinated recommendations for lung and thorax sonography. This document has been created within a transparent process, led by the German Society of Interdisciplinary Emergency and Acute Medicine e. V. (DGINA), and worked out by an expert panel and delegates from the societies. Sources of the first 200 cases were summarized. Typical thorax sonographic findings are presented. International sources or standards that were available in PubMed until May 24, 2020 were included. Using case studies and multimedia content, the document is intended to not only support users but also demonstrate quality features and the potential of chest and lung sonography. The German Society for Ultrasound in Medicine (DEGUM) is carrying out a multicenter study (study coordination at the TU Munich).

[Decisions on the allocation of intensive care resources in the context of the COVID-19 pandemic : Clinical and ethical recommendations of DIVI, DGINA, DGAI, DGIIN, DGNI, DGP, DGP and AEM. German version]. / Entscheidungen über die Zuteilung intensivmedizinischer Ressourcen im Kontext der COVID-19-Pandemie : Klinisch-ethische Empfehlungen der DIVI, der DGINA, der DGAI, der DGIIN, der DGNI, der DGP, der DGP und der AEM.

In view of the globally evolving Coronavirus Disease (COVID-19) pandemic, German hospitals rapidly expanded their intensive care capacities. However, it is possible that even with an optimal use of the increased resources, these will not suffice for all patients in need. Therefore, recommendations for the allocation of intensive care resources in the context of the COVID-19 pandemic have been developed by a multidisciplinary authors group with support of eight scientific medical societies. The recommendations for procedures and criteria for prioritisations in case of resource scarcity are based on scientific evidence, ethico-legal considerations and practical experience. Medical decisions must always be based on the need and the treatment preferences of the individual patient. In addition to this patient-centred approach, prioritisations in case of resource scarcity require a supra-individual perspective. In such situations, prioritisations should be based on the criterion of clinical prospect of success in order to minimize the number of preventable deaths due to resource scarcity and to avoid discrimination based on age, disabilities or social factors. Assessment of the clinical prospect of success should take into account the severity of the current illness, severe comorbidities and the patient's general health status prior to the current illness.

[Possibilities of employment of pregnant women in the health care system in association with SARS-CoV-2]. / Möglichkeiten der Beschäftigung von schwangeren Mitarbeiterinnen im Gesundheitssystem in Zusammenhang mit SARS-CoV-2.

Continued employment of pregnant women related to COVID (Corona Virus Disease) should only be considered if the risk of infection in the workplace is not higher than that of the general population. This option should therefore be carried out after an individual risk assessment with a precise description of the patient clientele and definition of the activities to be performed.