[German "Triage Act"-Regulation with fatal consequences]. / "Triagegesetz" ­ Regelung mit fatalen Folgen.

With the coming into force of § 5c of the Infection Protection Act (IfSG), the so-called Triage Act, on 14 December 2022, a protracted discussion has come to a provisional conclusion, the result of which physicians and social associations but also lawyers and ethicists are equally dissatisfied. The explicit exclusion of the discontinuation of treatment that has already begun in favor of new patients with better chances of success (so-called tertiary or ex-post triage) prevents allocation decisions with the aim of enabling as many patients as possible to beneficially participate in medical care under crisis conditions. The result of the new regulation is de facto a first come first served allocation, which is associated with the highest mortality even among individuals with limitations or disabilities and was rejected by a large margin as unfair in a population survey. Mandating allocation decisions based on the likelihood of success but which are not permitted to be consistently implemented and prohibiting, for example the use of age and frailty as prioritization criteria, although both factors most strongly determine the short-term probability of survival according to evident data, shows the contradictory and dogmatic nature of the regulation. The only remaining possibility is the consistent termination of treatment that is no longer indicated or desired by the patient, regardless of the current resource situation; however, if a different decision is made in a crisis situation than in a situation without a lack of resources, this practice would not be justified and would be punishable. Accordingly, the highest efforts must be set on legally compliant documentation, especially in the stage of decompensated crisis care in a region. The goal of enabling as many patients as possible to beneficially participate in medical care under crisis conditions is in any case thwarted by the new German Triage Act.

[Bed capacity management in times of the COVID-19 pandemic : A simulation-based prognosis of normal and intensive care beds using the descriptive data of the University Hospital Augsburg]. / Bettenkapazitätssteuerung in Zeiten der COVID-19-Pandemie : Eine simulationsbasierte Prognose der Normal- und Intensivstationsbetten anhand der deskriptiven Daten des Universitätsklinikums Augsburg.

BACKGROUND: Following the regional outbreak in China, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has spread all over the world, presenting the healthcare systems with huge challenges worldwide. In Germany the coronavirus diseases 2019 (COVID-19) pandemic has resulted in a slowly growing demand for health care with a sudden occurrence of regional hotspots. This leads to an unpredictable situation for many hospitals, leaving the question of how many bed resources are needed to cope with the surge of COVID-19 patients. OBJECTIVE: In this study we created a simulation-based prognostic tool that provides the management of the University Hospital of Augsburg and the civil protection services with the necessary information to plan and guide the disaster response to the ongoing pandemic. Especially the number of beds needed on isolation wards and intensive care units (ICU) are the biggest concerns. The focus should lie not only on the confirmed cases as the patients with suspected COVID-19 are in need of the same resources. MATERIAL AND METHODS: For the input we used the latest information provided by governmental institutions about the spreading of the disease, with a special focus on the growth rate of the cumulative number of cases. Due to the dynamics of the current situation, these data can be highly variable. To minimize the influence of this variance, we designed distribution functions for the parameters growth rate, length of stay in hospital and the proportion of infected people who need to be hospitalized in our area of responsibility. Using this input, we started a Monte Carlo simulation with 10,000 runs to predict the range of the number of hospital beds needed within the coming days and compared it with the available resources. RESULTS: Since 2 February 2020 a total of 306 patients were treated with suspected or confirmed COVID-19 at this university hospital. Of these 84 needed treatment on the ICU. With the help of several simulation-based forecasts, the required ICU and normal bed capacity at Augsburg University Hospital and the Augsburg ambulance service in the period from 28 March 2020 to 8 June 2020 could be predicted with a high degree of reliability. Simulations that were run before the impact of the restrictions in daily life showed that we would have run out of ICU bed capacity within approximately 1 month. CONCLUSION: Our simulation-based prognosis of the health care capacities needed helps the management of the hospital and the civil protection service to make reasonable decisions and adapt the disaster response to the realistic needs. At the same time the forecasts create the possibility to plan the strategic response days and weeks in advance. The tool presented in this study is, as far as we know, the only one accounting not only for confirmed COVID-19 cases but also for suspected COVID-19 patients. Additionally, the few input parameters used are easy to access and can be easily adapted to other healthcare systems.

[Internal hospital emergency management : Concepts for optimization of patient safety in hospitals]. / Innerklinisches Notfallmanagement : Konzepte zur Optimierung der Patientensicherheit im Krankenhaus.

Critical incidents in hospitals can often be predicted hours before the event and can mostly be detected earlier and presumably avoided. Quality management programs from US hospitals to reduce deaths following a severe postoperative complication (failure to rescue, FTR), have in this form not yet become established in Germany. A sensitive score-based early warning system for looming complications is decisive for successful in-hospital emergency management. In addition to measurement rounds where the frequency is adapted to the severity, this includes effective communication of the results to the ward physician, who in the best case scenario solves the problem alone. If the deployment of a medical rapid response emergency team (MET) is necessary, there must be clear chain of alarm pathways and the personnel on the ward must be able to take initial bridging action until the MET arrives. The MET provides 24/7 emergency and intensive medical expertise for peripheral wards and must be familiar with the location, well-equipped and trained. Communication skills are particularly required not only to be able to handle the immediate emergency situation but also to organize the downstream diagnostics and escalation of treatment; however, the MET is only one of the links in the in-hospital rescue chain, which can only improve the patient outcome when alerted in a timely manner. Feedback systems, such as participation in the German Resuscitation Registry, allow reflection of one's own performance in a national comparison. The chances offered by a MET will only be fully realized when it is integrated into an in-hospital emergency concept and this determines the added value for patient safety.

Diagnostic precision of triage algorithms for mass casualty incidents. English version.

BACKGROUND: Regarding survival and quality of life recent mass casualty incidents again emphasize the importance of early identification of the correct degree of injury/illness to enable prioritization of treatment amongst patients and their transportation to an appropriate hospital. The present study investigated existing triage algorithms in terms of sensitivity (SE) and specificity (SP) as well as its process duration in a relevant emergency patient cohort. METHODS: In this study 500 consecutive air rescue missions were evaluated by means of standardized patient records. Classification of patients was accomplished by 19 emergency physicians. Every case was independently classified by at least 3 physicians without considering any triage algorithm. Existing triage algorithms Primary Ranking for Initial Orientation in Emergency Medical Services (PRIOR), modified Simple Triage and Rapid Treatment (mSTaRT), Field Triage Score (FTS), Amberg-Schwandorf Algorithm for Triage (ASAV), Simple Triage and Rapid Treatment (STaRT), Care Flight, and Triage Sieve were additionally carried out computer based on each case, to enable calculation of quality criteria. RESULTS: The analyzed cohort had an age of (mean ± SD) 59 ± 25 years, a NACA score of 3.5 ± 1.1 and consisted of 57% men. On arrival 8 patients were deceased. Consequently, 492 patients were included in the analysis. The distribution of triage categories T1/T2/T3 were 10%/47%/43%, respectively. The highest diagnostic quality was achieved with START, mSTaRT, and ASAV yielding a SE of 78% and a SP ranging from 80-83%. The subgroup of surgical patients reached a SE of 95% and a SP between 85-91%. The newly established algorithm PRIOR exerted a SE of 90% but merely a SP of 54% in the overall cohort thereby consuming the longest time for overall decision. CONCLUSION: Triage procedures with acceptable diagnostic quality exist to identify the most severely injured. Due to its high rate of false positive results (over-triage) the recently developed PRIOR algorithm will cause overload of available resources for the severely injured within mass casualty incident missions. Non-surgical patients still are poorly identified by the available algorithms.

[Distribution of triage categories in terrorist attacks with mass casualties : Analysis and evaluation of European results from 1985 to 2017]. / Verteilung der Sichtungskategorien bei Terroranschlägen mit einem Massenanfall von Verletzten : Analyse und Bewertung der Ereignisse in Europa von 1985 bis 2017.

BACKGROUND: The incidence and character of civil mass casualty incidents (MCI) has changed in the last decades, in particular because of the rising number of terrorist attacks. As a result, the question arises whether commonly used tools of prevention and prehospital planning, including the distribution of triage categories (T1 severely injured/T2 seriously injured/T3 slightly injured) with 15%/20%/60% have to be modified. The rescue workers make the classification of the triage categories in MCIs at the scene. The aim of this article is to verify the planning size of variable distribution of the triage categories. MATERIAL AND METHODS: A total of 244 MCI with >9 casualties from 1 January 1985 to 31 May 2017 in Europe and Turkey were identified by a systematic literature search and analyzed with respect to the distribution of T in the first 24 h. RESULTS: An incidence of 10% T1, 17% T2, 49% T3 and 5% deaths was detected (median). Due to the previously use of the average of the triage categories in the contingency plan, the calculation showed a slightly different distribution from 15%/30%/55%. Of the events 7 were natural disasters, 227 terrorist attacks, 9 accidents and 1 mass panic. Natural disasters showed a higher than average death rate (11%), especially landslide incidents (67%). Civilian accidents showed a distribution of T of 10%/17%/55%, with train derailments having twice as many T1 patients and plane crashes just under twice as many T2 patients. In the case of terrorist attacks, the expected planning parameters were not quite achieved with 14%/15%/39%. Especially "combined hits" and amok driving had high incidences of T1 patients (18% and 21%, respectively). In addition, the T2 patients with 42% in amok driving and 48% in mass panics were well above the planning size of 20% and 30%, respectively. Calculation of the severity factor according to deBoer for amok driving and the result that at S ≥ 1.5 many seriously injured persons can be suspected, amok driving showed the highest degree of severity (S = 1.8) in our study. This indicates the severity of a disaster depending on the number of casualties per triage category.

[Diagnostic quality of triage algorithms for mass casualty incidents]. / Diagnostische Güte von Vorsichtungsalgorithmen für den Massenanfall von Verletzten und Erkrankten.

BACKGROUND: Regarding survival and quality of life, recent mass casualty incidents have once more emphasized the importance of early identification of the correct degree of injury or illness, to enable prioritizing treatment of patients and transportation to an appropriate hospital. The present study investigated international triage algorithms in terms of sensitivity (SE) and specificity (SP) as well as the process duration in a relevant emergency patient cohort. METHODS: A total of 500 consecutive air rescue missions were evaluated by means of standardized patient records. Interdisciplinary classification of patients was accomplished by 19 emergency physicians. Every case was independently classified according to the triage category by at least three physicians without considering any triage algorithm. The available triage algorithms PRIOR (Primary Ranking for Initial Orientation in Emergency Medical Services), mSTaRT (modified Simple Triage and Rapid Treatment), FTS (Field Triage Score), ASAV (Amberg-Schwandorf Algorithm for Triage), STaRT (Simple Triage and Rapid Treatment), CareFlight triage and Triage Sieve were additionally carried out for each patient in a computer-based procedure, to enable calculation of test quality criteria for all procedures. RESULTS: The analyzed cohort had a mean age of 59 ± 25 years (±SD), a National Advisory Committee for Aeronautics (NACA) score of 3.5 ± 1.1 and consisted of 57% men. On arrival 8 patients were already deceased, consequently 492 patients were included in the analysis. The distributions of triage categories I/II/III were 10%/47%/43%, respectively. The highest diagnostic quality was achieved with START, mSTaRT, and ASAV with 78% SE and 80-83% SP. The subgroup of surgical patients achieved 95% SE and 85-91% SP. The newly established algorithm PRIOR exerted an SE of 90% but an SP of only 54% in the overall cohort thereby taking the longest overall time for decisions. CONCLUSION: Triage procedures with acceptable diagnostic quality exist to identify the most severely injured. Due to its high rate of false positive results (overtriage) in this study, the recently developed PRIOR algorithm could result in exhaustion of available resources for the severely injured and therefore to undertreatment of correctly assigned triage category I cases within mass casualty incidents. Non-surgical patients are still poorly allocated by the available algorithms. Contribution available free of charge by "Free Access".

[Diagnostic investigation in emergency medicine: Why case history is crucial]. / Diagnostik in der Notfallmedizin: Warum die Anamnese entscheidend ist.

We present the preclinical case of a patient reporting chest pain. Pain impeded physical examination. Reviewing the patient's detailed medical history after analgesia revealed a connection between the reported pain and vomiting. This led to a suspicion of organ perforation. Thus, the patient was admitted to a surgical emergency room (ER) and Boerhaave's Syndrome was diagnosed. After deterioration in the ER, cardiopulmonal reanimation (CPR), and successful surgical treatment, the patient was transferred to the intensive care unit (ICU) seven hours after first contact.

[Risk management in anesthesia and critical care medicine]. / Risikomanagement in Anästhesie und Intensivmedizin.

Throughout its history, anesthesia and critical care medicine has experienced vast improvements to increase patient safety. Consequently, anesthesia has never been performed on such a high level as it is being performed today. As a result, we do not always fully perceive the risks involved in our daily activity. A survey performed in Swiss hospitals identified a total of 169 hot spots which endanger patient safety. It turned out that there is a complex variety of possible errors that can only be tackled through consistent implementation of a safety culture. The key elements to reduce complications are continuing staff education, algorithms and standard operating procedures (SOP), working according to the principles of crisis resource management (CRM) and last but not least the continuous work-up of mistakes identified by critical incident reporting systems.

[Management of anesthesia in endovascular interventions]. / Anästhesiologisches Management bei endovaskulären Gefäßeingriffen.

Cardiovascular diseases are one of the leading causes of morbidity and mortality in Germany. In these patients, the high-risk profile necessitates an interdisciplinary and multimodal approach to treatment. Endovascular interventions and vascular surgery have become established as an important element of this strategy in the past; however, the different anatomical localizations of pathological vascular alterations make it necessary to use a wide spectrum of procedural options and methods; therefore, the requirements for management of anesthesia are variable and necessitate a differentiated approach. Endovascular procedures can be carried out with the patient under general or regional anesthesia (RA); however, in the currently available literature there is no evidence for an advantage of RA over general anesthesia regarding morbidity and mortality, although a reduction in pulmonary complications could be found for some endovascular interventions. Epidural and spinal RA procedures should be carefully considered with respect to the risk-benefit ratio and consideration of the recent guidelines on anesthesia against the background of the current study situation and the regular use of therapy with anticoagulants. The following article elucidates the specific characteristics of anesthesia management as exemplified by some selected endovascular interventions.

[Risk management in anesthesia and critical care medicine]. / Risikomanagement in Anästhesie und Intensivmedizin.

Throughout its history, anesthesia and critical care medicine has experienced vast improvements to increase patient safety. Consequently, anesthesia has never been performed on such a high level as it is being performed today. As a result, we do not always fully perceive the risks involved in our daily activity. A survey performed in Swiss hospitals identified a total of 169 hot spots which endanger patient safety. It turned out that there is a complex variety of possible errors that can only be tackled through consistent implementation of a safety culture. The key elements to reduce complications are continuing staff education, algorithms and standard operating procedures (SOP), working according to the principles of crisis resource management (CRM) and last but not least the continuous work-up of mistakes identified by critical incident reporting systems.

IgM-enriched solution BT086 improves host defense capacity and energy store preservation in a rabbit model of endotoxemia.

INTRODUCTION: The therapeutic value of intravenous immunoglobulin (IVIG) as an adjuvant therapy in sepsis remains debatable. We hypothesized that intravenous administration of BT086, a predominantly IgM IVIG solution, would improve host defense in an established rabbit model of endotoxemia and systemic sepsis. METHODS: New Zealand white rabbits were randomized into the following four groups: (1) the negative control group without lipopolysaccharide (LPS, control), (2) the positive control group with LPS infusion (LPS group), (3) the albumin-treated LPS group (ALB+LPS group), and (4) the BT086-treated LPS group (BT086 + LPS group). A standardized amount of E. coli was intravenously injected into all of the animals. The vital parameters, the concentration of E. coli in the blood and other organs, the residual granulocyte phagocytosis activity, and the levels of the inflammatory mediators were measured. Histological changes in the lung and liver tissue were examined following autopsy. RESULTS: The elimination of E. coli from the bloodstream was expedited in the BT086-treated group compared with the LPS- and albumin-treated groups. The BT086 + LPS group exhibited higher phagocytic activity of polymorphonuclear neutrophils (PMNs) than the control and ALB+LPS groups. The liver energy stores were higher in the BT086 + LPS group than in the other groups. CONCLUSION: Our data suggest that the IgM-enriched IVIG has the potential to improve host defense in a rabbit model of endotoxemia. Studies using different animal models and dosages are necessary to further explore the potential benefits of IgM-enriched IVIG solutions.

[Obstructive shock]. / Obstruktiver Schock.

An acute obstruction of blood flow in central vessels of the systemic or pulmonary circulation causes the clinical symptoms of shock accompanied by disturbances of consciousness, centralization, oliguria, hypotension and tachycardia. In the case of an acute pulmonary embolism an intravascular occlusion results in an acute increase of the right ventricular afterload. In the case of a tension pneumothorax, an obstruction of the blood vessels supplying the heart is caused by an increase in extravascular pressure. From a hemodynamic viewpoint circulatory shock caused by obstruction is closely followed by cardiac deterioration; however, etiological and therapeutic options necessitate demarcation of cardiac from non-cardiac obstructive causes. The high dynamics of this potentially life-threatening condition is a hallmark of all types of obstructive shock. This requires an expeditious and purposeful diagnosis and a rapid and well-aimed therapy.

Cafedrine/theodrenaline in anaesthesia: influencing factors in restoring arterial blood pressure.

BACKGROUND: Hypotensive states that require fast stabilisation of blood pressure can occur during anaesthesia. In 1963, the 20:1 mixture of cafedrine/theodrenaline (Akrinor) was introduced in Germany for use in anaesthesia and emergency medicine in the first-line management of hypotensive states. Though on the market for many years, few pharmacodynamic data are available on this combination net beta-mimetic agent. AIM: This study aimed to examine the drug combination in real-life clinical practice and recorded time to 10 % mean arterial blood pressure (MAP) increase and heart rate. Furthermore, potential factors that influence drug effectiveness under anaesthesia were assessed. METHODS: Data were collected within a standardised anaesthesia protocol. A total of 353 consecutive patients (female/male = 149/204) who received cafedrine/theodrenaline after a drop in MAP ≥ 5% were included in the study. The time to 10 % increase in MAP, dosage of cafedrine/theodrenaline, volume loading, blood pressure and heart rate were monitored over time. RESULTS: Patients were a mean (standard deviation) of 64.4 ± 15.1 years old with a baseline MAP of 82 ± 14 mmHg, which dropped to a mean of 63 ± 10 mmHg during anaesthesia without gender differences. Cafedrine/theodrenaline (1.27 ± 1.0 mg/kg; 64 ± 50 µg/kg) significantly increased MAP (p < 0.001) by 11 ± 16 mmHg within 5 min, reaching peak values within 17.4 ± 9.0 min. Heart rate was not affected in a clinically significant manner. Cafedrine/theodrenaline induced a 10% MAP increase after 7.2 ± 4.6 min (women) and after 8.6 ± 6.3 min (men) (p = 0.018). Independent of gender, the dose of cafedrine/theodrenaline required to achieve the observed MAP increase of 14 ± 16 mmHg at 15 min was significantly different in patients with heart failure [1.78 ± 1.67 mg/kg (cafedrine)/89.0 ± 83.5 µg/kg (theodrenaline)] compared with healthy patients [1.16 ± 0.77 mg/kg (cafedrine)/58.0 ± 38.5 µg/kg (theodrenaline)] (p = 0.005). Concomitant medication with beta-blocking agents significantly prolonged the time to 10 % MAP increase [9.0 ± 7.0 vs. 7.3 ± 4.3 min (p = 0.008)]. CONCLUSION: Cafedrine/theodrenaline quickly restores MAP during anaesthesia. Female gender is associated with higher effectiveness, while heart failure and beta-blocker administration lower the anti-hypotonic effect. Prospective studies in defined patient populations are warranted to further characterise the effect of cafedrine/theodrenaline.

Nerve localization for peripheral regional anesthesia. Recommendations of the German Society of Anaesthesiology and Intensive Care Medicine.

The German Society of Anaesthesiology and Intensive Care Medicine (Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin, DGAI) established an expert panel to develop preliminary recommendations for nerve localization in peripheral regional anesthesia. Based on expert knowledge and the relatively limited data, the recommendations state how ultrasound and/or electrical nerve stimulation should be used in daily practice, and where and when local anesthetics should be injected. Moreover, it was defined under which conditions a peripheral nerve block under general anesthesia or deep sedation is applicable.Regarding the use of ultrasound the expert opinion was that out-of-plane and in-plane-techniques can be considered equal with respect to patient safety. Nevertheless, the direct or indirect visualization of the needle tip has to be assured. The injection of local anesthetics has to be visualized. Injections into nerves or those requiring an injection pressure should be avoided. The sole use of electrical nerve stimulation or ultrasound for nerve localization is still a suitable option as well as their combined use. To avoid accidental intraneural needle placement, an electrical current threshold ≥ 0.5 mA should be used. Moreover, it was stated that peripheral nerve blocks or continuous nerve block techniques under sedation or general anesthesia are applicable in adult patients who are unable to tolerate the block being performed in an awake state or have difficulty cooperating.This article is published in English.

[Inhaled anesthetics]. / Inhalative Anästhetika.

Inhaled anesthetics are inhaled via the lungs. They subsequently pass through the alveolocapillary membrane and diffuse into the blood to finally target the central nervous system and induce anesthesia. This principle of anesthesia induction was first described for diethylether in 1847. Nevertheless, the use of diethylether for anesthesia is obsolete and even the use of nitrous oxide (introduced for anesthesia in 1847) is declining in Germany. Almost all modern volatile anesthetics are halogenated methylethylethers in which fluorine is used as a halogen. All of these anesthetics depress myocardial contractility and induce hypotension. Depression of CO2 and hypoxia-induced respiration are other serious side effects. Further side effects are liver and kidney related but they are rare and not induced by anesthetics per se but preferentially by toxic metobolites. Another promising inhalative anesthetic is xenon which fulfils many aspects of an ideal inhalative anesthetic.