Welcome: Head of Department of Anesthesiology and Operative Intensive Care Medicine Campus Charité Mitte and Campus Virchow Klinikum Charité – Universitätsmedizin Berlin

Leopoldina Symposium Mission – Innovation: Telematics, eHealth and High-Definition Medicine in Patient-Centered Acute Medicine, Berlin, February 28th and 29th, 2020 - Openin

The Challenges of Intensive Care Medicine

Over the last decades, the number of ICU admissions in Germany has steadily increased. Simultaneously, patients are more likely to survive their critical illness, but survivors of critical illness frequently face functional impairments regarding their cognitive function, mental health, mobility and health-related quality of life, summarized as “Post-Intensive Care Syndrome (PICS)”. For clinicians, it is imperative to ensure the highest quality of ICU care and utilize evidence-based measures to mitigate those detrimental patient outcomes. In Germany, the DIVI has issued evidence-based “German Quality Indicators of Intensive Care” (QIs), which reflect current best practice in critical care. Their application can help reduce PICS burden. The ERIC-care-program at Charité – Universitätsmedizin Berlin utilizes telemedicine to enhance adherence to these QIs in hospitals of the Berlin metropolitan area. The newly established tele-ICU at Campus Virchow-Klinikum, which has high-quality audio-visual equipment and is staffed with experienced intensivists and nurses, provides daily, multiprofessional and QI-centered medical rounds for eleven centers with ICUs in the region. For a comprehensive evaluation, the ERIC-care-program is designed as a multicentre, pragmatic, cluster-randomized controlled trial with an open cohort stepped-wedge design with continuous recruitment. As such, it investigates the clinical effectiveness of a telemedical intervention in the ICU to improve the adherence to the DIVI QIs and is funded by the Innovation Committee of the Federal Joint Committee (01NVF16011). The ERIC-care-program aims to deliver highest quality of care to ICU patients, no matter where they are admitted.In den letzten Jahrzehnten ist die Zahl der Intensiveinweisungen in Deutschland stetig gestiegen. Gleichzeitig erhöht sich die Wahrscheinlichkeit, dass Patienten ihre kritische Erkrankung überleben. Überlebende kritischer Erkrankungen erfahren jedoch häufig eine funktionelle Beeinträchtigung hinsichtlich ihrer kognitiven Funktionen, psychischen Gesundheit, Mobilität und gesundheitsbezogenen Lebensqualität, welche unter dem Begriff Post-Intensive Care Syndrom (PICS) zusammengefasst werden. Für Kliniker ist es zwingend erforderlich, die höchste Qualität der Intensivpflege anzubieten und evidenzbasierte Maßnahmen zu nutzen, um diese nachteiligen Patientenergebnisse abzumildern. In Deutschland hat die DIVI evidenzbasierte „Qualitätsindikatoren der Intensivmedizin“ (QIs) herausgegeben, die die aktuell bewährte Praxis in der Intensivmedizin reflektieren. Ihre Anwendung kann helfen, die gesundheitliche Belastung von PICS zu reduzieren. Das ERIC-Programm an der Charité – Universitätsmedizin Berlin nutzt die Telemedizin, um eine bessere Einhaltung dieser QIs in Krankenhäusern der Metropolregion Berlin zu ermöglichen. Die neu eingerichtete Tele-Intensivstation am Campus Virchow-Klinikum verfügt über eine hochwertige audiovisuelle Ausstattung und ist mit erfahrenen Intensivmedizinern und Pflegekräften besetzt. Sie bietet elf regionalen Gesundheitszentren mit Intensivstationen tägliche multiprofessionelle und QI-zentrierte Visiten. Um das ERIC-Programm umfassend zu evaluieren, wurde eine multizentrische, pragmatische, cluster-randomisierte kontrollierte Studie mit offenen Kohorten, Stepped-Wedge-Design und kontinuierlicher Patientenrekrutierung konzipiert. Als solches untersucht sie die klinische Wirksamkeit einer telemedizinischen Intervention auf Intensivstationen, um die Einhaltung der DIVI-QIs zu verbessern. Sie wird vom Innovationsausschuss des Gemeinsamen Bundesausschusses gefördert (01NVF16011). Das ERIC-Programm zielt darauf ab, Patienten auf der Intensivstation höchste Versorgungsqualität zu bieten, egal wo sie aufgenommen werden

Postoperative Delirium and Cognitive Trajectories

Postoperative Delirium (POD) is a frequent and serious complication after surgery. Depending on predisposing and precipitating factors, the incidence ranges between 10 - 50 %. POD is associated with loss of autonomy, increased morbidity and mortality and long-term neurocognitive disorders (NCD) in approximately 5 - 10 % of the POD patients. This article will focus on mechanisms involved in the development of POD and NCD, such as inflammation, toxicity, hypoxia/perfusion deficit and metabolism. Innovation Fund projects, such as “Prehabilitation of Frail Elderly Patients Prior to Elective Surgery (PRÄP-GO)” and the quality contract for “Prevention of Postoperative Delirium in the care of Elderly Patients” will be discussed. A focus will be placed on pathomechanisms and the prevention of risk factors while employing patient-centered principles.Das postoperative Delir (POD) ist eine häufige und schwerwiegende Komplikation nach einer Operation. Je nach prädisponierenden und auslösenden Faktoren liegt die Inzidenz zwischen 10 - 50 %. Bei etwa 5 - 10 % der Patienten wird POD mit einem Verlust der Autonomie, erhöhter Morbidität und Letalität, sowie langfristigen neurokognitiven Störungen (NCD) verbunden. Dieser Beitrag befasst sich mit den Mechanismen, die an der Entwicklung von POD und NCD beteiligt sind, wie z. B. Entzündungen, Toxizität, Hypoxie/Perfusionsdefizit und Metabolismus. Projekte des Innovationsfonds, wie die „Prähabilitation von älteren Patienten mit Gebrechlichkeitssyndrom vor elektiven Operationen (PRÄP-GO)“ und der Qualitätsvertrag zur „Prävention des postoperativen Delirs in der Versorgung älterer Patienten“, werden diskutiert. Ein Schwerpunkt liegt auf Pathomechanismen und der Prävention von Risikofaktoren unter Anwendung patientenzentrierter Prinzipien

The Mission of Innovation

This article provides a brief overview of the relevance, objectives and content of the Nova Acta Leopoldina “Mission – Innovation: Telematics, eHealth and High-Definition Medicine in Patient-Centered Acute Medicine”.Dieser Beitrag gibt einen kurzen Überblick über die Relevanz, die Ziele und den Inhalt der Nova Acta Leopoldina “Mission – Innovation: Telematik, eHealth und High Definition Medicine in der patientenzentrierten Akutmedizin”

Dexmedetomidine Prevents Lipopolysaccharide-Induced MicroRNA Expression in the Adult Rat Brain

During surgery or infection, peripheral inflammation can lead to neuroinflammation, which is associated with cognitive impairment, neurodegeneration, and several neurodegenerative diseases. Dexmedetomidine, an α-2-adrenoceptor agonist, is known to exert anti-inflammatory and neuroprotective properties and reduces the incidence of postoperative cognitive impairments. However, on the whole the molecular mechanisms are poorly understood. This study aims to explore whether dexmedetomidine influences microRNAs (miRNAs) in a rat model of lipopolysaccharide (LPS)-induced neuroinflammation. Adult Wistar rats were injected with 1 mg/kg LPS intraperitoneal (i.p.) in the presence or absence of 5 µg/kg dexmedetomidine. After 6 h, 24 h, and 7 days, gene expressions of interleukin 1-β (IL1-β), tumor necrosis factor-α (TNF-α), and microRNA expressions of miR 124, 132, 134, and 155 were measured in the hippocampus, cortex, and plasma. Dexmedetomidine decreased the LPS-induced neuroinflammation in the hippocampus and cortex via significant reduction of the IL1-β and TNF-α gene expressions after 24 h. Moreover, the LPS-mediated increased expressions of miR 124, 132, 134, and 155 were significantly decreased after dexmedetomidine treatment in both brain regions. In plasma, dexmedetomidine significantly reduced LPS- induced miR 155 after 6 h. Furthermore, there is evidence that miR 132 and 134 may be suitable as potential biomarkers for the detection of neuroinflammation. View Full-Tex

Postoperative Anaemia Might Be a Risk Factor for Postoperative Delirium and Prolonged Hospital Stay: A Secondary Analysis of a Prospective Cohort Study

Background: Postoperative anaemia is a frequent surgical complication and in contrast to preoperative anaemia has not been validated in relation to mortality, morbidity and its associated health economic effect. Postoperative anaemia can predispose postoperative delirium through impairment of cerebral oxygenation. The aim of this secondary analysis is to investigate the association of postoperative anaemia in accordance with the sex specific World Health Organization definition of anaemia to postoperative delirium and its impact on the duration of hospital stay. Methods: A secondary analysis of the prospective multicentric observational CESARO-study was conducted. 800 adult patients undergoing elective surgery were enrolled from various operative disciplines across seven hospitals ranging from university hospitals, district general hospitals to specialist clinics of minimally invasive surgery in Germany. Patients were classified as anaemic according to the World Health Organization parameters, setting the haemoglobin level cut off below 12g/dl for females and below 13g/dl for males. Focus of the investigation were patients with acute anaemia. Patients with present preoperative anaemia or missing haemoglobin measurement were excluded from the sample set. Delirium screening was established postoperatively for at least 24 hours and up to three days, applying the validated Nursing Delirium Screening Scale. Results: The initial sample set contained 800 patients of which 183 were suitable for analysis in the study. Ninety out of 183 (49.2%) suffered from postoperative anaemia. Ten out of 93 (10.9%) patients without postoperative anaemia developed a postoperative delirium. In the group with postoperative anaemia, 28 (38.4%) out of 90 patients suffered from postoperative delirium (odds ratio 3.949, 95% confidence interval, (1.358-11.480)) after adjustment for NYHA-stadium, severity of surgery, cutting/suture time, duration of anaesthesia, transfusion of packed red cells and sedation status with Richmond Agitation Scale after surgery. Additionally, patients who suffered from postoperative anaemia showed a significantly longer duration of hospitalisation (7.75 vs. 12.42 days, odds ratio = 1.186, 95% confidence interval, 1.083-1.299, after adjustments). Conclusion: The study results reveal that postoperative anaemia is not only a frequent postsurgical complication with an incidence probability of almost 50%, but could also be associated with a postoperative delirium and a prolonged hospitalisation

Case Report Intravenous Lormetazepam during Sedation Weaning in a 26-Year-Old Critically Ill Woman

Recent evidence revealed that sedation is related to adverse outcomes including a higher mortality. Despite this fact, patients sometimes require deep sedation for a limited period of time to control, for example, intracranial hypertension. In particular in these cases, weaning from sedation is often challenging due to emerging agitation, stress, and delirium. The submitted research letter reports a rare case of severe and persisting agitation that was unresponsive to all available treatments. Ultimately, lormetazepam which has recently become available for intravenous use in Germany resolved the problem by stress-reduction and anxiolysis without leading to measurable sedation

Practice of sedation and analgesia in German intensive care units: results of a national survey

INTRODUCTION: Sedation and analgesia are provided by using different agents and techniques in different countries. The goal is to achieve early spontaneous breathing and to obtain an awake and cooperative pain-free patient. It was the aim of this study to conduct a survey of the agents and techniques used for analgesia and sedation in intensive care units in Germany. METHODS: A survey was sent by mail to 261 hospitals in Germany. The anesthesiologists running the intensive care unit were asked to fill in the structured questionnaire about their use of sedation and analgesia. RESULTS: A total of 220 (84%) questionnaires were completed and returned. The RAMSAY sedation scale was used in 8% of the hospitals. A written policy was available in 21% of hospitals. For short-term sedation in most hospitals, propofol was used in combination with sufentanil or fentanyl. For long-term sedation, midazolam/fentanyl was preferred. Clonidine was a common part of up to two-thirds of the regimens. Epidural analgesia was used in up to 68%. Neuromuscular blocking agents were no longer used. CONCLUSION: In contrast to the US 'Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult', our survey showed that in Germany different agents, and frequently neuroaxial techniques, were used