Die extrakorporale kardiopulmonale Reanimation („extracorporeal cardiopulmonary resuscitation“ [ECPR]) kann bei hochselektierten Patient*innen mit refraktärem Kreislaufstillstand und potenziell reversibler Ursache des Kreislaufstillstands als Rettungsstrategie erwogen werden. Sowohl die ECPR selbst als auch die anschließende Therapie unter ECLS („extracorporeal life support“) sind komplex und ressourcenintensiv. Eine robuste Evidenz für eine Überlegenheit der ECPR gegenüber der konventionellen kardiopulmonalen Reanimation fehlt bislang. Die Implementierung und Aufrechterhaltung eines leistungsfähigen ECPR-Programms erfordert im Sinne der Qualitätssicherung klar strukturierte Prozesse, definierte Kommunikationswege und eine belastbare institutionelle Infrastruktur. Die Gewährleistung einer flächendeckenden und intersektoralen Versorgungsqualität setzt eine kooperative Zusammenarbeit vieler notwendiger Fachdisziplinen voraus. Das vorliegende Konsensuspapier aktualisiert das 2018 publizierte Dokument und definiert ein gemeinsames Rahmenkonzept zentraler struktureller, prozessualer und klinischer Anforderungen.
Background: Observation units are an established component of modern emergency departments. However, limited data are available on the operational, governance, and staffing concepts underlying their performance. Objective: To describe and evaluate the Clinical Decision Unit model of a university interdisciplinary emergency department. Materials and methods: This retrospective cohort study included all adult nontrauma patients treated in 2024. Organizational structure, care pathways, resource utilization, and outcomes were analyzed. A simulation estimated additional inpatient bed demand in a hypothetical scenario without the Clinical Decision Unit model. Results: Among 17,001 patients, 10,327 (60.7%) received inpatient management within the Clinical Decision Unit model. Of these, 3880 (37.6%) completed their care within the emergency department, whereas 6447 (62.4%) were transferred to an inpatient specialty ward. Patients receiving definitive care within the emergency department remained for a median of 9.6 h and required comparable diagnostic and therapeutic resources. In the hypothetical scenario without the Clinical Decision Unit model, an additional 5485 bed-days would have been required on inpatient wards; after accounting for the bed capacity required within the emergency department, the net capacity difference was 4191 bed-days, equivalent to a mean of 11.5 beds. Conclusion: A structured Clinical Decision Unit model can complete inpatient care within the emergency department and preserve inpatient capacity. Experienced interprofessional teams, clear clinical decision-making responsibility, and appropriate emergency care infrastructure are essential prerequisites.
Acute heart failure (AHF) is among the most common causes of emergency department, intermediate care, and intensive care unit admission and remains associated with substantial early mortality despite advances in contemporary therapy. The first 120 min of management are particularly critical, as this period determines not only respiratory and hemodynamic stabilization, but also trigger identification, decongestion strategy, and the foundation for subsequent prognostic improvement. This CME article provides a practical, phenotype-based approach to the early management of AHF. The proposed strategy is centered on the rapid classification of patients according to congestion ("wet" vs. "dry") and perfusion ("warm" vs. "cold") status. Stabilization and diagnostic work-up must occur simultaneously. Early assessment should focus on identifying acute coronary syndrome, clinically relevant arrhythmias, hypertensive crisis, pulmonary embolism, structural heart disease, and infectious triggers. In addition to clinical examination, electrocardiography, blood gas analysis, and biomarkers, point-of-care ultrasound with lung ultrasound and focused echocardiography play a pivotal role in the first-line evaluation. From a therapeutic perspective, early noninvasive ventilation in cardiogenic pulmonary edema, prompt vasodilation in hypertensive presentations, and effective decongestion with intravenous loop diuretics constitute the core interventions. In cases of insufficient response, escalation strategies such as sequential nephron blockade or selective use of vasoactive agents should be considered. Structured reassessment at short intervals is essential to detect persistent congestion, evolving hypoperfusion, inadequate therapeutic response, or overlooked differential diagnoses. The article emphasizes that successful acute management must already establish the transition toward guideline-directed long-term therapy during the first hours of hospitalization, including early initiation of evidence-based heart failure medication once hemodynamic stabilization has been achieved.
Background End-of-life intensive care interventions correlate with a reduced quality of life of dying patients. Reassessment of clinical indication and patients' preferences, along with potential changes in goals of care, is needed. Changes in goals of care are not sufficiently documented in some instances. Objectives Analysis of terms used to document changes in goals of care in medical records and documented therapy adjustment. Materials and methods Retrospective analysis of n = 160 records of deceased patients from four intensive care units (n = 40 per unit) of one university hospital. Descriptive and qualitative content analysis were performed using Excel (Microsoft Corporation, Redmond, Washington, USA) and MAXQDA 24 (VERBI Software GmbH, Berlin, Germany). Results Documentation of changes in goals of care were found in 78% (125/160) of the records. Terms describing changes could be categorized into eleven groups: 'Palliative' (n = 29), 'Treatment withdrawal' (n = 19), 'Best supportive care/symptom control' (n = 18), 'Do not escalate' (n = 13), 'Limitation of therapy' (n = 11), 'Changes in goals of care' (n = 10), 'Do not resuscitate/do not intubate' (n = 10), 'Freeze' (n = 7), 'Specific interventions' (n = 3), 'Mixed terms of changes in goals of care' (n = 3) and 'Others' (n = 2). In the sample, descriptive differences were observed in the frequency of terms depending on ward and patients' age. Therapy adjustments varied in some cases between the terms. For example, mechanical ventilation was discontinued most frequently in the group 'Palliative', at 71% (17/24). Conclusion Recommended terms to describe goals of care were used inconsistently. Changes in measures and the terms showed only partially similar patterns. A uniformly defined understanding of the team and a structured application of the terms could support the interdisciplinary implementation of changes in goals of care.
