Abstract Background Endotracheal intubation is a high-stakes intervention in emergency airway management, with patient safety closely linked to first-pass success and avoidance of repeated attempts. The Frankfurt Intubation Device (FID) is a bougie-inspired intubation device intended to provide fast protection against aspiration once positioned in the trachea. Methods This dual-center randomized crossover simulation study used an easy-to-intubate airway manikin. Ninety participants were divided into three groups of different experience (anesthesiologists, non-physician critical care staff, and medical students) to perform intubation with the Frankfurt Intubation Device (FID) and a standard endotracheal tube with stylet in randomized order. The primary outcome was non-inferiority of time to airway protection, measured from laryngoscope insertion to inflation of a cuffed device positioned in the trachea (T2; Δ = 5 s). Secondary outcomes included first-pass success, tooth damage, and exploratory assessment of training effects, with additional time-based outcomes assessed descriptively. Results Across all participants, the FID was non-inferior to the endotracheal tube with stylet for T2 (mean paired difference − 0.77 s, 95% CI − 2.50 to 0.97; non-inferiority margin 5 s). Exploratory analyses demonstrated consistent non-inferiority for T2 across experience groups (G1–G3) and randomization sequences. First-pass success was high in both arms (FID 96.7% vs. ET+stylet 94.4%), while tooth damage occurred less frequently with the FID (7.8% vs. 14.4%). Training effects were observed in the simulator. Conclusion In this standardized simulation study using an easy-to-intubate airway manikin, the Frankfurt Intubation Device demonstrated non-inferiority to conventional endotracheal intubation with stylet for time to airway protection. Secondary findings support continued staged evaluation of the FID, particularly in more challenging airway scenarios and among users with limited airway experience, where differences in procedural performance may become more apparent. Trial registration Not applicable (simulation study).

On May 4, 2024, the 23rd Obstetric Anesthesia Symposium took place as an event of the scientific working group "Obstetric Anesthesia" of the German Society of Anesthesiology (DGAI). As in previous years, topics related to obstetric anesthesiological practice were presented by experienced speakers and intensively discussed with the participants. Among other things, personal "recipes" and recommendations for daily practice, various options for analgesia in the delivery room, patient blood management in the delivery room, alternatives to obstetric epidurals, management of post-puncture headaches, and analgesia after cesarean section were addressed.

On May 4, 2024, the 23rd Obstetric Anesthesia Symposium took place as an event of the scientific working group "Obstetric Anesthesia" of the German Society of Anesthesiology (DGAI). As in previous years, topics related to obstetric anesthesiological practice were presented by experienced speakers and intensively discussed with the participants. Among other things, personal "recipes" and recommendations for daily practice, various options for analgesia in the delivery room, patient blood management in the delivery room, alternatives to obstetric epidurals, management of post-puncture headaches, and analgesia after cesarean section were addressed.

Background Endotracheal intubation can be a lifesaving procedure but poses risks, particularly in emergency situations. Inexperienced users benefit from user-friendly devices for successful intubation.Methods This feasibility study assessed the Frankfurt Intubation Device (FID), developed for ease of use with early aspiration protection and a redundant light source. 30 medical students with minimal intubation experience were randomised to start with endotracheal tube (ET)+stylet or FID. After standardised instruction, each performed one manikin intubation per device. Usability was assessed on a 10-point Likert scale (1-10), with lower scores indicating better usability.Results Participants rated the FID as easy to use (median (Md)=3 (2;3)) and suitable for everyday practice (Md=3 (2;4)). They preferred the FID (Md=3 (2;4)) and believed it could become a new standard, requiring minimal training (Md=2 (1.25;3)) while enhancing safety (Md=2 (2;3)). No significant difference in preference was found between FID and ET+stylet. Time to airway protection was 13 (11;16.5) s and 13 (11.5;20) s for ET+stylet, and 16 (13;19.5) s and 14 (12;15.5) s for FID. Time to ventilation increased for ET+stylet from 18 (16.5;23) s to 20 (18;28) s, but decreased for FID from 38 (34.5;46) s to 34 (30.5;38) s. All participants succeeded on the first attempt without dental trauma.Conclusion The FID is easy to use, requires minimal training and shows strong acceptance. The time to ventilation was slower than with ET+stylet in this manikin model but may improve in difficult airways. An industry cooperation is aspired.

Kardiovaskuläre und respiratorische Komplikationen sind häufige Ursache perioperativer Todesfälle. Die Inzidenz wird mit 1–7 % für respiratorische und 2–20 % für kardiovaskuläre Komplikationen angegeben. Die wichtigsten perioperativen Komplikationen werden in diesem Kapitel erörtert.

Introduction: The medical development in the previous 15 years and the changes in treatment reality of the comprehensive elective treatment of abdominal aortic aneurysms necessitate a re-evaluation of the quality assurance guidelines of the Federal Joint Committee in Germany (QBAA-RL). In the current version this requires a specialist further training quota for nursing personnel in intensive care wards of 50%. The quota was determined in 2008 based on expert opinions, although a direct empirical evidence base for this does not exist. Methods: Representatives from the fields of patient representation, physicians, nursing personnel and other relevant interface areas were invited to participate in a modified Delphi procedure. Following a comprehensive narrative literature search, a survey and focus group discussions with national and international experts, a total of three anonymized online-based voting rounds were carried out for which previously determined key statements were assessed with a 4-point Likert scale (totally disagree up to totally agree). In addition, the expert panel had also defined a recommendation for a minimum quota for the specialist training of nursing personnel on intensive care wards in the treatment of abdominal aortic aneurysms, whereby an a priori agreement of 80% of the participants was defined as the consensus limit. Results: Overall, 37 experts participated in the discussions and three successive voting rounds (participation rate 89%). The panel confirmed the necessity of a re-evaluation of the guideline recommendations and recommended the introduction of a shift-related minimum quota of 30% of the full-time equivalent of nursing personnel on intensive care wards and the introduction of structured promotional programs for long-term elevation of the quota. Conclusion: In this national Delphi procedure with medical and nursing experts as well as representatives of patients, the fundamental benefits and needs of professional specialist qualifications in the field of intensive care medicine were confirmed. The corresponding minimum quota for specialist further training of intensive care nursing personnel should generally apply without limitations to specific groups. The expert panel stipulates a shift-related minimum quota for intensive care nursing personnel with specialist training of 30% of the nursing personnel on intensive care wards and the obligatory introduction of structured and transparent promotion programs for the long-term enhancement.

Die zeitgerechte Bestimmung und Bewertung von Laborparametern bei Patienten mit akuten lebens- oder organbedrohlichen Erkrankungen und Erkrankungszuständen in der Notaufnahme oder auf Intensivstationen kann für die Diagnosestellung, den Therapiebeginn und das Ergebnis essenziell sein. Ziel des Positionspapiers ist es, die zeitlichen Anforderungen an die Bereitstellung von labormedizinischen Ergebnissen in der Notfall- und Intensivmedizin zu definieren. Aus der Dringlichkeit lassen sich Anforderungen an Point-of-Care-Testung (POCT) und (zentrales) Labor ableiten. Expertengruppen aus der Deutschen Gesellschaft für Klinische Chemie und Laboratoriumsmedizin (DGKL) und der Deutschen Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin (DIVI) entwickelten unter Nutzung von nationalen und internationalen Leitlinien, Reviewartikeln und Originalarbeiten eine Einteilung zur Dringlichkeit von Laborbestimmungen sowie Empfehlungen zu den erforderlichen Rahmenbedingungen und zur Qualitätssicherung. Es werden 3 Stufen der Dringlichkeit für die Bestimmung der gängigsten Laborparameter anhand der Turnaround Time definiert: Notfall 1, mit einer Turnaround Time von maximal 15 min; Notfall 2, mit einer Turnaround Time von maximal 60 min; dringlicher Fall, mit einer Turnaround Time innerhalb von 4 h. Zusätzlich wird eine Empfehlung zur Bereitstellung der Ergebnisse zur Hauptvisite auf der Intensivstation und der Notaufnahme gegeben. Die Empfehlungen erlauben, die organisatorischen und apparativen Regelungen für jedes Krankenhaus anhand der medizinischen Anforderungen an die Dringlichkeit auszurichten.

BACKGROUND AND OBJECTIVES:The timely determination and evaluation of laboratory parameters in patients with acute life- or organ-threatening diseases and disease states in the emergency room or intensive care units can be essential for diagnosis, initiation of therapy, and outcome. The aim of the position paper is to define the time requirements for the provision of laboratory results in emergency and intensive care medicine. Requirements for point-of-care testing (POCT) and the (central) laboratory can be derived from the urgency. METHODS:Expert groups from the DGKL (Deutsche Gesellschaft für Klinische Chemie und Laboratoriumsmedizin) and DIVI (Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin) developed a classification about the urgency for the determination of laboratory parameters as well as recommendations on the necessary organizational framework and quality assurance measures using national and international guidelines, review articles, and original papers. RESULTS:Three levels of urgency are defined, based on the turnaround time of the most common laboratory parameters: emergency 1, with a turnaround time of no more than 15 min; emergency 2, with a turnaround time of a maximum of 60 min; urgent case, with a turnaround time within 4 h. In addition, a recommendation is made when to provide the results for the main ward rounds in the intensive care unit and the emergency department. CONCLUSIONS:The recommendations allow the organizational and technical regulations for each hospital to be aligned with the urgency of the provision of the test results to the medical team based on the medical requirements.

Zusammenfassung Einleitung Die medizinischen Weiterentwicklungen in den vergangenen 15 Jahren und die veränderte Versorgungsrealität bei der flächendeckenden elektiven Behandlung des Bauchaortenaneurysmas machen eine Reevaluation der Qualitätssicherungsrichtlinie des Gemeinsamen Bundesausschuss in Deutschland (QBAA-RL) erforderlich. Diese fordert derzeit in der aktuellen Fassung eine Fachweiterbildungsquote für Pflegefachpersonen der Intensivstation in Höhe von 50 %. Die Quote wurde 2008 auf dem Boden von Expertenmeinungen festgelegt, ohne dass bisher eine direkte empirische Evidenzbasis dafür existiert. Methoden Vertreter:innen aus den Bereichen Patient:innenvertreter, Ärzt:innen, Pflegefachpersonen sowie weiteren relevanten Schnittstellenbereichen wurden zur Teilnahme an einem modifizierten Delphi-Verfahren eingeladen. Nach einer umfassenden narrativen Literaturrecherche, einer Umfrage sowie Fokusgruppendiskussionen mit nationalen und internationalen Expert:innen erfolgte die Durchführung von insgesamt drei anonymisierten onlinebasierten Abstimmungsrunden, bei denen zuvor festgelegte Kernaussagen mit einer 4‑Punkt-Likert-Skala („stimme ganz und gar nicht zu“ bis „stimme voll und ganz zu“) bewertet wurden. Das Expert:innenpanel hat außerdem eine Empfehlung für eine Mindestquote für die Fachweiterbildung von Pflegefachpersonen auf der Intensivstation bei der Behandlung des Bauchaortenaneurysmas festgelegt, wobei a priori eine Zustimmung in Höhe von 80 % der Teilnehmenden als Konsensusgrenze festgelegt wurde. Ergebnisse Insgesamt haben 37 Expert:innen an den Diskussionen und drei sukzessiven Abstimmungsrunden teilgenommen (Teilnahmerate 89 %). Das Panel hat die Notwendigkeit einer Reevaluation der Richtlinienempfehlungen bestätigt und empfahl die Einführung einer schichtbezogenen Mindestquote in Höhe von 30 % der Vollzeitäquivalente der Pflegefachpersonen der Intensivstation sowie die Einführung strukturierter Förderprogramme zur langfristigen Erhöhung der Quote. Schlussfolgerung In diesem nationalen Delphi-Verfahren mit ärztlichen und pflegerischen Expert:innen sowie Patientenvertreter:innen wurde der grundsätzliche Nutzen und Bedarf der beruflichen Fachqualifikation im Bereich der Intensivmedizin bestätigt. Die entsprechenden Mindestquoten für eine Fachweiterbildung von Intensivpflegefachpersonen sollten demnach ohne Einschränkung auf spezifische Leistungsgruppen generell gelten. Das Expert:innenpanel fordert eine schichtbezogene Mindestquote an Intensivpflegefachpersonen mit Fachweiterbildung in Höhe von 30 % der Pflegefachpersonen auf der Intensivstation und die verpflichtende Einführung strukturierter und transparenter Förderprogramme zu deren langfristiger Erhöhung.

Interhospital transport of acute respiratory distress syndrome (ARDS) patients bears transport-associated risks. It is unknown how interhospital extracorporeal membrane oxygenation (ECMO) transfer of COVID-19 patients by mobile ECMO units affects ARDS mortality. We compared the outcome of 94 COVID-19 patients cannulated in primary care hospitals and retrieved by mobile ECMO-teams to that of 84 patients cannulated at five German ECMO centers. Patients were recruited from March 2020 to November 2021. Twenty-six transports were airborne, 68 were land-based. Age, sex, body-mass-index, Simplified Acute Physiology Score (SAPS) II, days invasively ventilated, and P/F-Ratio before ECMO initiation were similar in both groups. Counting only regional transports (≤250 km), mean transport distance was 139.5 km ± 17.7 km for helicopter (duration 52.5 ± 10.6 minutes) and 69.8 km ± 44.1 km for ambulance or mobile intensive care unit (duration 57.6 ± 29.4 minutes). Overall time of vvECMO support (20.4 ± 15.2 ECMO days for transported patients vs. 21.0 ± 20.5 for control, p = 0.83) and days invasively ventilated (27.9 ± 18.1 days vs. 32.6 ± 25.1 days, p = 0.16) were similar. Overall mortality did not differ between transported patients and controls (57/94 [61%] vs. 51/83 [61%], p = 0.43). COVID-19 patients cannulated and retrieved by mobile ECMO-teams have no excess risk compared with patients receiving vvECMO at experienced ECMO centers. Patients with COVID-19-associated ARDS, limited comorbidities, and no contraindication for ECMO should be referred early to local ECMO centers.

Aims and Methods: We evaluated an ultrasound score from 0 to 32 points in eight pulmonary regions to monitor critically ill COVID-19 patients. The score was correlated to surrogate parameters of disease severity, i.e., the oxygenation index, respiratory support, mortality, plasma interleukin-6, and WHO and ARDS classifications. Results: A total of 27 patients were repeatedly examined, and 71 examinations were evaluated. Patients with severe COVID-19 scored higher (median 17) than those with moderate disease (median 11, p < 0.01). The score did not differentiate between stages of ARDS as defined by the Berlin criteria (p = 0.1) but could discern ARDS according to the revised ESICM definition (p = 0.002). Non-survivors had higher ultrasound scores than survivors (median 18.5 vs. 14, p = 0.04). The score correlated to the oxygenation index (ρ = −0.56, p = 0.03), and changes in the score between examinations correlated to changes in oxygenation (ρ = −0.41, p = 0.16). The correlation between the score and interleukin-6 was ρ = 0.35 (p < 0.001). The interrater reliability for the score was ICC = 0.87 (p < 0.001). Conclusions: The ultrasound score is a reliable tool that might help monitor disease severity and may help stratify the risk of mortality.

ZusammenfassungDas akute Lungenversagen des Erwachsenen (ARDS) ist nach wie vor mit einer hohen Mortalität von ca. 40% belastet – eine große Herausforderung für die Intensivmedizin. Dieser Beitrag erläutert, bei welchen Befundkonstellationen die Lungenersatzverfahren ECMO (extrakorporale Membranoxygenierung) und ECCO2R (extrakorporale CO2-Elimination) als Rescue-Therapie zum Einsatz kommen können und worauf dabei zu achten ist.

In the context of the coronavirus disease 2019 (COVID-19) pandemic, many retrospective single-centre or specialised centre reports have shown promising mortality rates with the use of extracorporeal membrane oxygenation (ECMO) therapy. However, the mortality rate of an entire country throughout the COVID-19 pandemic remains unknown.The primary objective is to determine the hospital mortality in COVID-19 patients receiving venovenous ECMO (VV-ECMO) and veno-arterial ECMO (VA-ECMO) therapy. Secondary objectives are the chronological development of mortality during the pandemic, the analysis of comorbidities, age and complications.Cohort study.Inpatient data from January 2020 to September 2021 of all hospitals in Germany were analysed.All COVID-19-positive patients who received ECMO therapy were analysed according to the appropriate international statistical classification of diseases and related health problem codes (ICDs) and process key codes (OPSs).The primary outcome was the hospital mortality.In total, 4279 COVID-19-positive patients who received ECMO therapy were analysed. Among 404 patients treated with VA-ECMO and 3875 treated with VV-ECMO, the hospital mortality was high: 72% (n = 291) for VA-ECMO and 65.9% (n = 2552) for VV-ECMO. A total of 43.2% (n = 1848) of all patients were older than 60 years with a hospital mortality rate of 72.7% (n = 172) for VA-ECMO and 77.6% (n = 1301) for VV-ECMO. CPR was performed in 44.1% (n = 178) of patients with VA-ECMO and 16.4% (n = 637) of patients with VV-ECMO. The mortality rates widely varied from 48.1 to 84.4% in individual months and worsened from March 2020 (59.2%) to September 2021 (78.4%).In Germany, a large proportion of elderly patients with COVID-19 were treated with ECMO, with an unacceptably high hospital mortality. Considering these data, the unconditional use of ECMO therapy in COVID-19 must be carefully considered and advanced age should be considered as a relative contraindication.

STUDY OBJECTIVE:We explored the feasibility of a Clinical Decision Support System (CDSS) to guide evidence-based perioperative anticoagulation. DESIGN:Prospective randomised clinical management simulation multicentre study. SETTING:Five University and 11 general hospitals in Germany. PARTICIPANTS:We enrolled physicians (anaesthesiologist (n = 73), trauma surgeons (n = 2), unknown (n = 1)) with different professional experience. INTERVENTIONS:A CDSS based on a multiple-choice test was developed and validated at the University Hospital of Frankfurt (phase-I). The CDSS comprised European guidelines for the management of anticoagulation in cardiology, cardio-thoracic, non-cardio-thoracic surgery and anaesthesiology. Phase-II compared the efficiency of physicians in identifying evidence-based approach of managing perioperative anticoagulation. In total 168 physicians were randomised to CDSS (PERI-KOAG) or CONTROL. MEASUREMENTS:Overall mean score and association of processing time and professional experience were analysed. The multiple-choice test consists of 11 cases and two correct answers per question were required to gain 100% success rate (=22 points). MAIN RESULTS:In total 76 physicians completed the questionnaire (n = 42 PERI-KOAG; n = 34 CONTROL; attrition rate 54%). Overall mean score (max. 100% = 22 points) was significantly higher in PERI-KOAG compared to CONTROL (82 ± 15% vs. 70 ± 10%; 18 ± 3 vs. 15 ± 2 points; P = 0.0003). A longer processing time is associated with significantly increased overall mean scores in PERI-KOAG (≥33 min. 89 ± 10% (20 ± 2 points) vs. <33 min. 73 ± 15% (16 ± 3 points), P = 0.0005) but not in CONTROL (≥33 min. 74 ± 13% (16 ± 3 points) vs. <33 min. 69 ± 9% (15 ± 2 points), P = 0.11). Within PERI-KOAG, there is a tendency towards higher results within the more experienced group (>5 years), but no significant difference to less (≤5 years) experienced colleagues (87 ± 10% (19 ± 2 points) vs. 78 ± 17% (17 ± 4 points), P = 0.08). However, an association between professional experience and success rate in CONTROL has not been shown (71 ± 8% vs. 70 ± 13%, 16 ± 2 vs. 15 ± 3 points; P = 0.66). CONCLUSIONS:CDSS significantly improved the identification of evidence-based treatment approaches. A precise usage of CDSS is mandatory to maximise efficiency.

BACKGROUND In the context of the coronavirus disease 2019 (COVID-19) pandemic, many retrospective single-centre or specialised centre reports have shown promising mortality rates with the use of extracorporeal membrane oxygenation (ECMO) therapy. However, the mortality rate of an entire country throughout the COVID-19 pandemic remains unknown. OBJECTIVES The primary objective is to determine the hospital mortality in COVID-19 patients receiving venovenous ECMO (VV-ECMO) and veno-arterial ECMO (VA-ECMO) therapy. Secondary objectives are the chronological development of mortality during the pandemic, the analysis of comorbidities, age and complications. DESIGN Cohort study. SETTING Inpatient data from January 2020 to September 2021 of all hospitals in Germany were analysed. PARTICIPANTS All COVID-19-positive patients who received ECMO therapy were analysed according to the appropriate international statistical classification of diseases and related health problem codes (ICDs) and process key codes (OPSs). MAIN OUTCOME MEASURES The primary outcome was the hospital mortality. RESULTS In total, 4279 COVID-19-positive patients who received ECMO therapy were analysed. Among 404 patients treated with VA-ECMO and 3875 treated with VV-ECMO, the hospital mortality was high: 72% (n = 291) for VA-ECMO and 65.9% (n = 2552) for VV-ECMO. A total of 43.2% (n = 1848) of all patients were older than 60 years with a hospital mortality rate of 72.7% (n = 172) for VA-ECMO and 77.6% (n = 1301) for VV-ECMO. CPR was performed in 44.1% (n = 178) of patients with VA-ECMO and 16.4% (n = 637) of patients with VV-ECMO. The mortality rates widely varied from 48.1 to 84.4% in individual months and worsened from March 2020 (59.2%) to September 2021 (78.4%). CONCLUSION In Germany, a large proportion of elderly patients with COVID-19 were treated with ECMO, with an unacceptably high hospital mortality. Considering these data, the unconditional use of ECMO therapy in COVID-19 must be carefully considered and advanced age should be considered as a relative contraindication.

Objectives Rising prevalence of multidrug-resistant organisms (MDRO) is a major health problem in patients with liver cirrhosis. The impact of MDRO colonization in liver transplantation (LT) candidates and recipients on mortality has not been determined in detail. Methods Patients consecutively evaluated and listed for LT in a tertiary German liver transplant center from 2008 to 2018 underwent screening for MDRO colonization including methicillin-resistant Staphylococcus aureus (MRSA), multidrug-resistant gram-negative bacteria (MDRGN), and vancomycin-resistant enterococci (VRE). MDRO colonization and infection status were obtained at LT evaluation, planned and unplanned hospitalization, three months upon graft allocation, or at last follow-up on the waiting list. Results In total, 351 patients were listed for LT, of whom 164 (47%) underwent LT after a median of 249 (range 0-1662) days. Incidence of MDRO colonization increased during waiting time for LT, and MRDO colonization was associated with increased mortality on the waiting list (HR = 2.57, p<0.0001. One patients was colonized with a carbapenem-resistant strain at listing, 9 patients acquired carbapenem-resistant gram-negative bacteria (CRGN) on the waiting list, and 4 more after LT. In total, 10 of these 14 patients died. Conclusions Colonization with MDRO is associated with increased mortality on the waiting list, but not in short-term follow-up after LT. Moreover, colonization with CRGN seems associated with high mortality in liver transplant candidates and recipients.

BACKGROUND:Acquired platelet dysfunction is a common element of trauma-induced coagulopathy and has been linked to increased mortality. The aim of the study was to describe the prevalence of platelet dysfunction in patients with acute intracranial bleeding.METHODS:Patients diagnosed with acute intracranial bleeding were screened for eligibility. Patients with an urgent need for craniotomy were enrolled in this prospective monocentric study. Platelet function analyses using multiple electrode aggregometry (TRAPtest, ASPItest and ADPtest) and conventional coagulation tests were performed. The area under the aggregation curves of the ASPItest and ADPtest were defined as primary outcome variables.RESULTS:Seventy-seven patients were screened for eligibility, and 49 patients were ultimately enrolled in the study. In 14 patients (29%), clinically relevant platelet dysfunction was observed. Of those, 8 patients were treated with antiaggregatory medication at the time of study inclusion. Six patients (12%) were diagnosed with acute acquired platelet dysfunction.CONCLUSIONS:Decreased platelet function was present in nearly one-third of patients with acute intracranial bleeding. Hemotherapy algorithms for the treatment of coagulopathy in this cohort should incorporate aggregometric measures to enable rapid goal-directed therapy.

Der standardisierte Ablauf der Intubation von Intensivpatienten reduziert lebensbedrohliche Komplikationen im Rahmen der Atemwegssicherung – insbesondere beim schwierigen Atemweg. Definierte Abläufe sowie festgelegte und trainierte „Airway Tools“ geben dem durchführenden Team Sicherheit und führen zu Routine und Patientensicherheit.