Results from the ETHICUS-2 study

Background: End-of-life care is common in German intensive care units (ICUs) but little is known about daily practice. Objectives: To study the practice of end-of-life care. Methods: Prospectively planned, secondary analysis comprising the German subset of the worldwide Ethicus-2 Study (2015-2016) including consecutive ICU patients with limitation of life-sustaining therapy or who died. Results: Among 1092 (13.7%) of 7966 patients from 11 multidisciplinary ICUs, 967 (88.6%) had treatment limitations, 92 (8.4%) died with failed CPR, and 33 (3%) with brain death. Among patients with treatment limitations, 22.3% (216/967) patients were discharged alive from the ICU. More patients had treatments withdrawn than withheld (556 [57.5%] vs. 411 [42.5%], p < 0.001). Patients with treatment limitations were older (median 73 years [interquartile range (IQR) 61-80] vs. 68 years [IQR 54-77]) and more had mental decision-making capacity (12.9 vs. 0.8%), advance directives (28.6 vs. 11.2%), and information about treatment wishes (82.7 vs 33.3%, all p < 0.001). Physicians reported discussing treatment limitations with patients with mental decision-making capacity and families (91.3 and 82.6%, respectively). Patient wishes were unknown in 41.3% of patients. The major reason for decision-making was unresponsiveness to maximal therapy (34.6%). Conclusions: Treatment limitations are common, based on information about patients' wishes and discussion between stakeholders, patients and families. However, our findings suggest that treatment preferences of nearly half the patients remain unknown which affects guidance for treatment decisions

Anaesthetic efficacy and postinduction hypotension with remimazolam compared with propofol:a multicentre randomised controlled trial

Remimazolam, a short-acting benzodiazepine, may be used for induction and maintenance of total intravenous anaesthesia, but its role in the management of patients with multiple comorbidities remains unclear. In this phase 3 randomised controlled trial, we compared the anaesthetic efficacy and the incidence of postinduction hypotension during total intravenous anaesthesia with remimazolam vs. propofol. A total of 365 patients (ASA physical status 3 or 4) scheduled for elective surgery were assigned randomly to receive total intravenous anaesthesia with remimazolam (n = 270) or propofol (n = 95). Primary outcome was anaesthetic effect, quantified as the percentage of time with Narcotrend® Index values ≤ 60, during surgery (skin incision to last skin suture), with a non-inferiority margin of -10%. Secondary outcome was the incidence of postinduction hypotensive events. Mean (SD) percentage of time with Narcotrend Index values ≤ 60 during surgery across all patients receiving remimazolam (93% (20.7)) was non-inferior to propofol (99% (4.2)), mean difference (97.5%CI) -6.28% (-8.89–infinite); p = 0.003. Mean (SD) number of postinduction hypotension events was 62 (38.1) and 71 (41.1) for patients allocated to the remimazolam and propofol groups, respectively; p = 0.015. Noradrenaline administration events (requirement for a bolus and/or infusion) were also lower in patients allocated to remimazolam compared with propofol (14 (13.5) vs. 20 (14.6), respectively; p &lt; 0.001). In conclusion, in patients who were ASA physical status 3 or 4, the anaesthetic effect of remimazolam was non-inferior to propofol.</p

Comparison of post-COVID-19 symptoms in patients infected with the SARS-CoV-2 variants delta and omicron - results of the Cross-Sectoral Platform of the German National Pandemic Cohort Network (NAPKON-SUEP)

Purpose The influence of new SARS-CoV-2 variants on the post-COVID-19 condition (PCC) remains unanswered. Therefore, we examined the prevalence and predictors of PCC-related symptoms in patients infected with the SARS-CoV-2 variants delta or omicron. Methods We compared prevalences and risk factors of acute and PCC-related symptoms three months after primary infection (3MFU) between delta- and omicron-infected patients from the Cross-Sectoral Platform of the German National Pandemic Cohort Network. Health-related quality of life (HrQoL) was determined by the EQ-5D-5L index score and trend groups were calculated to describe changes of HrQoL between different time points. Results We considered 758 patients for our analysis (delta: n = 341; omicron: n = 417). Compared with omicron patients, delta patients had a similar prevalence of PCC at the 3MFU (p = 0.354), whereby fatigue occurred most frequently (n = 256, 34%). HrQoL was comparable between the groups with the lowest EQ-5D-5L index score (0.75, 95% CI 0.73–0.78) at disease onset. While most patients (69%, n = 348) never showed a declined HrQoL, it deteriorated substantially in 37 patients (7%) from the acute phase to the 3MFU of which 27 were infected with omicron. Conclusion With quality-controlled data from a multicenter cohort, we showed that PCC is an equally common challenge for patients infected with the SARS-CoV-2 variants delta and omicron at least for the German population. Developing the EQ-5D-5L index score trend groups showed that over two thirds of patients did not experience any restrictions in their HrQoL due to or after the SARS-CoV-2 infection at the 3MFU. Clinical Trail registration The cohort is registered at ClinicalTrials.gov since February 24, 2021 (Identifier: NCT04768998)

Randomized investigation of heart failure therapy in patients with advanced cancer at risk of cardiac wasting: rationale and design of the EMPATICC trial

Aims: End‐stage cancer may resemble a heart failure (HF)‐like phenotype marked by cardiac wasting, dysfunction, and symptoms such as dyspnoea, congestion, and impaired physical function. The EMPATICC (EMPower the heArt of patients with TermInal Cancer using Cardiac medicines) trial evaluates the safety and efficacy of optimized HF therapy in patients with advanced cancer to improve self‐care ability. Methods: EMPATICC is a multicentre, investigator‐initiated, randomized, double‐blind, controlled, proof‐of‐concept trial employing a joint cardio‐oncology care approach. Patients were randomized 1:1 to optimized HF therapy (sacubitril/valsartan, empagliflozin, ivabradine, ferric carboxymaltose) plus usual care, or usual care alone, for 30 days, followed by a 30‐day open‐label extension. Eligible patients had stage IV solid tumours (per Union for International Cancer Control), were receiving palliative care, had a 1–6 month life expectancy, and were on optimized analgesia. At baseline, first patients had to meet ≥2 criteria of the following indicating cardiovascular risk: heart rate ≥70 bpm, N‐terminal pro‐B‐type natriuretic peptide ≥600 pg/ml, elevated high‐sensitivity troponin, left ventricular ejection fraction &lt;55%, left ventricular mass loss &gt;15%, transferrin saturation &lt;20%, or moderate/high likelihood of HF with preserved ejection fraction (based on the HFA‐PEFF score); and they had to meet at least one criterion of the following indicating functional limitation: ≥6 s to walk 4 m, inability to wash ≥3 days of the last 7 days, or symptoms of dyspnoea at rest. Enrolment ended 30 January 2025; 93 patients completed randomization. The primary endpoint is a hierarchical composite (analysed by win ratio): (1) days alive and able to wash, (2) 4 m walking ability, and (3) patient global assessment of well‐being. Conclusions: EMPATICC evaluates whether HF therapy can improve function and well‐being in advanced cancer, potentially reshaping care in this population

Nurses' perceptions of aids and obstacles to the provision of optimal end of life care in ICU

Contains fulltext : 172380.pdf (publisher's version ) (Open Access

Adipositas und Beatmung

ZusammenfassungPatienten mit Übergewicht weisen bezüglich ihrer Atemmechanik und des daraus folgenden Gasaustausches einige Besonderheiten auf. Dazu gehören die hohe Neigung zu Atelektasen mit Ausbildung eines intrapulmonalen Shunts, die erniedrigte funktionelle Residualkapazität und die besondere Neigung zu Bronchusobstruktion. Bei der maschinellen Beatmung von Patienten mit Adipositas und akutem Lungenversagen sind daher die Einstellung eines optimalen PEEP und die Reduktion von Atelektasen durch Lagerungs-und Rekrutierungsmanöver von besonderer Bedeutung. Gerade weil die Aspekte lungenschonender Beatmung für Adipöse wenig untersucht sind, sollte eine individuelle Einstellung der Beatmungsparameter vorgenommen werden.</jats:p