The Ethics Section of the German Interdisciplinary Association of Critical Care and Emergency Medicine (DIVI) recently published a documentation for decisions to withhold or withdraw life-sustaining therapies. The wish to donate organs was not considered explicitly. Therefore the Ethics Section and the Organ Donation and Transplantation Section of the DIVI together with the Ethics Section of the German Society of Medical Intensive Care Medicine and Emergency Medicine worked out a supplementary footnote for the documentation form to address the individual case of a patient's wish to donate organs.

Verletzungen, insbesondere Schädel-Hirn-Traumata, oder bestimmte Erkrankungen und ihre jeweiligen Folgen können zur Folge haben, dass die davon betroffenen Patienten trotz aller intensivmedizinischen Bemühungen daran versterben. Sollte eine Organspende nach deren Tod prinzipiell in Betracht kommen, sind regelhaft intensivmedizinische Maßnahmen zur Aufrechterhaltung der Organe erforderlich, die aber nicht mehr dem betreffenden Patienten zunutze sein können. Dies kann zu einem ethischen Zielkonflikt zwischen einer würdevollen Begleitung des Patienten am Lebensende und einem erweiterten Behandlungsbedarf zur bestmöglichen Organprotektion führen – besonders dann, wenn der Patient vorab eine Therapiebegrenzung bestimmt hat. Die Sektion Ethik und die Sektion Organspende und -transplantation der Deutschen Interdisziplinären Vereinigung für Intensiv- und Notfallmedizin (DIVI) haben in mehreren Sitzungen und einer Telefonkonferenz eine Entscheidungshilfe erarbeitet, die den Entscheidungsprozess hinsichtlich des Behandlungsumfangs bei potenziellen Organspendern zunächst auf die Bewertung 5 einzelner Dimensionen fokussiert, nämlich die Gewissheit des irreversiblen Hirnfunktionsausfalls, den Organspendewunsch des Patienten, seinen Willen zur Therapiebegrenzung, die Eingriffsintensität der zur Organprotektion erforderlichen erweiterten Behandlungsmaßnahmen und die Wahrscheinlichkeit einer erfolgreichen Organprotektion. Aus der Zusammenschau der Einzelbewertungen, die anhand eines dafür entwickelten Netzdiagramms verdeutlicht werden kann, lässt sich bei aller Komplexität der Fragestellung doch erkennen, ob eine Fortführung oder ggf. Erweiterung der intensivmedizinischen Maßnahmen ethisch gerechtfertigt, fragwürdig oder gar ausgeschlossen erscheint. Die beschriebene Vorgehensweise kann ethische Zielkonflikte hinsichtlich des Therapieumfangs bei dem todgeweihten Patienten entschärfen helfen, bei denen eine Organspende medizinisch prinzipiell möglich erscheint.

Zusammenfassung Die Sektion Ethik der Deutschen Interdisziplinären Vereinigung für Intensiv- und Notfallmedizin (DIVI) veröffentlichte vor kurzem einen Dokumentationsbogen „Therapiebegrenzung“, der die Entscheidungen abbildet, welche medizinischen Maßnahmen unterlassen werden sollen, weil sie nicht (mehr) indiziert sind und/oder vom Patienten nicht gewünscht werden. Der individuelle Fall eines Organspendewunsches wurde hierbei nicht explizit berücksichtig. Daher wurde von der Sektion Ethik und der Sektion Organspende und Organtransplantation der DIVI unter Mitarbeit der Sektion Ethik der Deutschen Gesellschaft für Internistische Intensivmedizin und Notfallmedizin eine Ergänzung vorgenommen. In der Fußnote wurde für den Fall eines Organspendewunsches ein entsprechender Hinweis in der aktuellen Version der „Dokumentation Therapiebegrenzung“ aufgenommen.

MedKlin IntensivmedNotfmed2019 ·114:46–52 https://doi.org/10.1007/s00063-018-0514-y Published online: 30 November 2018 © The Author(s) 2018 G. Neitzke · H. Burchardi · G. Duttge · C. Hartog · R. Erchinger · P. Gretenkort · A. Michalsen · M. Mohr · F. Nauck · F. Salomon · H. Stopfkuchen · N. Weiler · U. Janssens 1 Institute for Medical History, Ethics and Philosophy, Hannover Medical School, Hannover, Germany 2 Bovenden, Germany 3 Institute for Criminal Sciences—Department for Criminal Medicaland Biolaw, Georg-August-University Göttingen, Göttingen, Germany

The task of physicians is to maintain life, to protect and re-establish health as well as to alleviate suffering and to accompany the dying until death, under consideration of the self-determination rights of patients. Increasingly more and differentiated options for this are becoming available in intensive care medicine. Within the framework of professional responsibility physicians must decide which of the available treatment options are indicated. This process of decision-making is determined by answering the following question: when and under which circumstances is induction or continuation of intensive care treatment justified? In addition to the indications, the advance directive of the patient is the deciding factor. Medical indications represent a scientifically based estimation that a therapeutic measure is suitable in order to achieve a defined therapy target with a given probability. The ascertainment of the patient directive is achieved in a graded process depending on the state of consciousness of the patient. The present article offers orientation assistance to physicians for these decisions which are an individual responsibility.

We describe the use of low molecular weight heparin to treat venous thrombosis in two very low-birth-weight pre-term infants (GA: 30 and 27 weeks) both with genetic and acquired prothrombotic risk factors. Initially both infants were treated with unfractionated heparin. Since in one infant no effect on the thrombus size was observed and in the other infant there was an increase in size, the anticoagulation therapy was switched to subcutaneously injected low molecular heparin (Enoxaparin). During enoxaparin therapy the anti-Xa-level was carefully monitored and dosages were adjusted accordingly. Partial resolution of the thrombosis was achieved in both infants during enoxaparin therapy. No clot extension or recurrence of thrombosis occurred. An accidental overdose of Enoxaparin (100 times the required dosage) was administered to one infant without any consequences. Our data suggest that the use of low molecular weight heparin (Enoxaparin) for treatment of venous thrombosis in our two preterm infants was practical, safe and effective.

Hypotension is diagnosed in a high percentage of very low birth weight infants, particularly in the first 24 hours after birth and the resultant clinical approach is to support the blood pressure vigorously. However, the research base is not yet available to give a definite answer to the question, which blood pressure is really unacceptable in a given clinical situation. The clinical approach usually relies on reference blood pressure data or on clinical considerations. Reference blood pressure ranges established from observations of rather stable preterm infants and commonly used in "normal" premature infants are age- and weight related so-called "normal" blood pressures and "rules of thumb" while cerebral autoregulation adapted or outcome related lower limits of arterial blood pressure could be promising alternatives. Clinical signs, results of laboratory studies and cardiac function monitoring are tools used in stable and unstable premature infants for assessing if an acute blood pressure is adequate to prevent tissue malperfusion. In this rather unsatisfactory situation there is a growing body of evidence that also in premature infants systemic or regional blood flow and not blood pressure are the crucial hemodynamic parameters and that also in this age group there is at best a weak correlation between mean arterial blood pressure and left ventricular output or regional blood flow.

Antenatal ultrasound screening for birth defects is increasingly becoming a routine procedure of prenatal care. Prenatal detection of malformations and subsequent adjustment of obstetric management are essential for secondary prevention. It is unknown whether ultrasound screening is effective in all pregnant women, or should only be performed in high risk populations. From 1990-1994, 20,248 livebirths, stillbirths and abortions underwent physical and sonographic examinations and anamnestic data were collected. To identify the high risk group, case control analyses of births with one of the 23 selected major malformations (controls) were performed with respect to anamnestic risk factors. All women had at least three routine ultrasound scans. The selected malformations were diagnosed in 298 children; 95 (30.3 per cent) were diagnosed antenatally. Detection rates were: CNS (68.6 per cent), gastro-intestinal tract (42.3 per cent), urinary system (24.1) per cent), heart (5.9 per cent). Complications during pregnancy were calculated as indicators of congenital anomalies: premature labour (< 28 week) OR 4.7 (3.8-5.9), placental insufficiency OR 1.9 (1.1-2.7) and vaginal bleeding OR 1.5 (1.2-1.8), etc. Antenatal routine ultrasound screening is not effective risk populations. Anamnestic risk factors risk factors during pregnancy may be essential indicators for identifying high risk populations. We propose screening of the described high risk pregnancies (about 22 per cent of all pregnancies) to be performed by specially trained and highly experienced ultrasonographers to increase sensitivity rates and benefit cost effectiveness.

Ascending infection is a serious threat in pregnancies complicated by preterm premature rupture of the membranes (PROM). In a controlled randomized prospective pilot study (n = 18) we have evaluated the effect of intravenous IgM enriched immunoglobulin given to the mothers 24-48 hours after preterm PROM in reducing ascending infection. Using a validated infection score from laboratory and clinical data at birth, we found a significant reduction of probable infection in the neonates of the treatment group compared to the control group (p = 0.0022). Histopathological investigation of the placentas, membranes and umbilical cords revealed significantly lower stages and grades of chorioamnionitis in the treatment group (p = 0.036). From these preliminary results we conclude, that intravenous broad spectrum immunoglobulin given antenatally to patients with preterm PROM may reduce ascending infection. However, studies with a much larger cohort of patients are necessary to confirm these preliminary results and to detect potential clinical benefits from this treatment mode.

During the last years, noninvasive determination of the aortic valve area by Doppler echocardiography using the continuity equation became popular. However, a systematic valve area underestimation of about 15% compared to invasive measurements using the Gorlin formula has been reported. The cause therefore is unknown. The purpose of this study was to evaluate whether the valve area underestimation by the Doppler method might be due to differences in the hydrodynamic background of both methods. This comparison is facilitated by the fact that the Gorlin formula is based on the continuity equation. Compared to the continuity equation, there are four changes within the Gorlin formula: (1) the additional use of a discharge coefficient, which leads to valve area overestimation by the factor 1.17; (2) neglect of the pre-stenotic velocity, causing further overestimation by the factor 1.036 (in mild stenosis this factor may be 1.18 and more); (3) the wrong calculation of the mean pressure drop, which leads to a mean change by the factor 0.95, and (4) the incorrect substitution of the height by the pressure drop in the derivation of the Gorlin formula causes underestimation by the factor 0.97. Combining these four factors results in valve area overestimation of the Gorlin formula compared to the continuity equation by the factor 1.12. This explains to a large extent the valve area underestimation by the continuity equation.

Zerebrale Krampfanfälle sind in der Neonatalperiode ein häufiges Symptom einer neurologischen Störung. Die Angaben über ihre tatsächliche Inzidenz in unselektierten Kollektiven schwanken zwischen 4,2 und 12 auf 1000 Neugeborene (Brown u. Minns 1980; Volpe 1989); wesentlich häufiger allerdings ist der Neonatologe mit dem Problem der Neugeborenenkrämpfe konfrontiert: auf Früh- und Neugeborenen-Intensivstationen beobachtet man zerebrale Anfälle bei bis zu 20% der Patienten (Gal et al. 1982; Painter 1989).