The treatment of patients with acute respiratory distress syndrome (ARDS) involves lung protective mechanical ventilation and, if necessary, the use of extracorporeal procedures, such as ex tracorporeal membrane oxygenation (ECMO). Although invasive procedures can adequately treat both hypercapnia and hypoxaemia, they are potentially associated with life threatening compli cations. Therefore, noninvasive appro aches appear particularly attractive from a clinical perspective. Most recently, a device based on double piston system (Ventilution (R)) synchronised with each other and integrated into the breathing circuit has been clinically introduced which does support CO2 removal by reduction of mechanical dead space. In brief, CO2containing expiration gas is substituted 1:1 with fresh breathing gas from the ventilator. Here we report on a patient who was treated with this non invasive technique. He had undergone a pneumonectomy one year earlier and had recently developed pneumonia after surgery for a femur fracture. The patient required tracheal intubation due to res piratory insufficiency under noninvasive ventilation. Under the anti infective therapy that had been initiated, he de veloped pronounced hypercapnia with acidosis and a clinically relevant oxyge nation disorder, for which reason ECMO therapy was considered. After applying noninvasive technology and therapy in the prone position for 72 hours, lung function recovered and the patient could be extubated 6 days after intubation. The Ventilution (R) system is a clinically promi sing treatment option. However, further and larger clinical studies are needed to determine the indications and the potential benefit of its use in critically ill patients.
This article reports on a criminal trial against an anesthesiologist who was charged with murder in the context of a change in therapeutic goals for a critically ill intensive care patient. Based on the course of the trial and its outcome (acquittal after 420 days of pretrial detention), legal and clinical practical implications are derived, along with guidance for the practical implementa tion, execution, communication, and documentation of changes in therapeutic goals, in order to avoid or defend against criminal liability.
In accordance with the statutes of the Association of the Scientific Medical Societies in Germany (AWMF), 25 professional medical or labor organizations were asked to nominate experts to devise the S3 Guideline "Perioperative Treatment of Patients with Frailty". This interdisciplinary and interprofessional guideline group included scientists, clinicians, patient representatives as well methodical counseling by the AWMF. Development proceeded in accordance with the AWMF provisions and applying the evaluation framework Appraisal of Guidelines for Research and Evaluation (AGREE II). Key objectives consisted in the formulation of recommendations for presurgical assessment and preventive and therapeutic measures capable of positively influencing mortality and morbidity and, in particular, postsurgical complications. The guideline work was based on previously defined PICO questions and a systematic literature survey which included both screening and full-text assessment. Evidence tables and recommendation texts were created, the quality of evidence assessed in compliance with the GRADE approach and the recommendations subsequently adopted in a multi-stage procedure (including Online Delphi Procedure plus subsequent Consensus Conference). The guideline was approved by the professional societies involved and published by the AWMF. The recommendations of the current version are based on publications released between Jan. 1, 2000 and Nov. 20, 2024 which were found in the scope of a systematic literature plus more recent publications. Eighteen new recommendations were formulated and two adaptations derived from existing guidelines were adopted. Concomitantly, the guideline makes re-ference to the existence of two research gaps.
