Jörg Martin

Evidence and consensus-based German guidelines for the management of analgesia, sedation and delirium in intensive care--short version.

Targeted monitoring of analgesia, sedation and delirium, as well as their appropriate management in critically ill patients is a standard of care in intensive care medicine. With the undisputed advantages of goal-oriented therapy established, there was a need to develop our own guidelines on analgesia and sedation in intensive care in Germany and these were published as 2nd Generation Guidelines in 2005. Through the dissemination of these guidelines in 2006, use of monitoring was shown to have improved from 8 to 51% and the use of protocol-based approaches increased to 46% (from 21%). Between 2006–2009, the existing guidelines from the DGAI (Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin) and DIVI (Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin) were developed into 3rd Generation Guidelines for the securing and optimization of quality of analgesia, sedation and delirium management in the intensive care unit (ICU). In collaboration with another 10 professional societies, the literature has been reviewed using the criteria of the Oxford Center of Evidence Based Medicine. Using data from 671 reference works, text, diagrams and recommendations were drawn up. In the recommendations, Grade “A” (very strong recommendation), Grade “B” (strong recommendation) and Grade “0” (open recommendation) were agreed. As a result of this process we now have an interdisciplinary and consensus-based set of 3rd Generation Guidelines that take into account all critically illness patient populations. The use of protocols for analgesia, sedation and treatment of delirium are repeatedly demonstrated. These guidelines offer treatment recommendations for the ICU team. The implementation of scores and protocols into routine ICU practice is necessary for their success.

Validity and reliability of the DDS for severity of delirium in the ICU.

Introduction: Until now, there has been no gold standard for monitoring delirium in intensive care unit (ICU) patients. In this prospective cohort study, a new score, the Delirium Detection Score (DDS), for severity of delirium in the ICU was evaluated.Methods: After ethical approval and written informed consent, intensive care doctors and nurses assessed 1073 consecutive patients in surgical ICUs using the DDS together with the Ramsay Sedation Scale (RSS). The DDS is composed of eight criteria (orientation, hallucination, agitation, anxiety, seizures, tremor, paroxysmal sweating, and altered sleepwake rhythm). Additionally, intensive care doctors had to document the Sedation-Agitation Scale (SAS) combined with a defined clinical assessment. For interrater reliability, pair of evaluators assessed patients in a blinded fashion at the same time.Results: RSS1 (9%) was associated with a significantly (p<0.001) higher DDS than RSS levels 2–6. The DDS increased with the severity of delirium (p< 0.001). The receiver operating characteristics (ROC) for the differentiation between no delirium (SAS<4) and symptoms of delirium at all (SAS 5–7) showed an area under the curve (AUC) of 0.802 (95% confidential interval (CI): 0.719–0.898; p<0.001) and 69% sensitivity and 75% specificity was determined. For reliability, a Cronbach’s α of 0.667 was calculated. The paired comparisons revealed an intraclass correlation between 0.642 and 0.758.Conclusion: The DDS demonstrated good validity with excellent sensitivity and specificity for delirium. The severity of delirium can be more accurately estimated by the DDS. By its composition of several items, the DDS might help to start a symptom-guided therapy immediately.

[Prevention, diagnosis, treatment, and follow-up care of sepsis. First revision of the S2k Guidelines of the German Sepsis Society (DSG) and the German Interdisciplinary Association for Intensive and Emergency Care Medicine (DIVI)].

(Orientiert an der Definition der Agency for Health Care Policy and Research fur die „Clinical Practice Guidelines“ der USA): „Leitlinien sind systematisch entwickelte Darstellungen und Empfehlungen mit dem Zweck, Arzte und Patienten bei der Entscheidung uber angemessene Masnahmen der Krankenversorgung (Pravention, Diagnostik, Therapie und Nachsorge) unter spezifischen medizinischen Umstanden zu unterstutzen.“ Leitlinien geben den Stand des Wissens (Ergebnisse von kontrollierten klinischen Studien und Wissen von Experten) uber effektive und angemessene Krankenversorgung zum Zeitpunkt der „Drucklegung“ wieder. In Anbetracht der unausbleiblichen Fortschritte wissenschaftlicher Erkenntnisse und der Technik mussen periodische Uberarbeitungen, Erneuerungen und Korrekturen unternommen werden. Die Empfehlungen der Leitlinien konnen nicht unter allen Umstanden angemessen genutzt werden. Die Entscheidung daruber, ob einer bestimmten Empfehlung gefolgt werden soll, muss vom Arzt unter Berucksichtigung der beim individuellen Patienten vorliegenden Gegebenheiten und der verfugbaren Ressourcen getroffen werden.

Quality indicators in intensive care medicine: why? Use or burden for the intensivist.

In order to improve quality (of therapy), one has to know, evaluate and make transparent, one’s own daily processes. This process of reflection can be supported by the presentation of key data or indicators, in which the real as-is state can be represented. Quality indicators are required in order to depict the as-is state. Quality indicators reflect adherence to specific quality measures. Continuing registration of an indicator is useless once it becomes irrelevant or adherence is 100%. In the field of intensive care medicine, studies of quality indicators have been performed in some countries. Quality indicators relevant for medical quality and outcome in critically ill patients have been identified by following standardized approaches. Different German societies of intensive care medicine have finally agreed on 10 core quality indicators that will be valid for two years and are currently recommended in German intensive care units (ICUs).

Peer reviewing critical care: a pragmatic approach to quality management.

Critical care medicine frequently involves decisions and measures that may result in significant consequences for patients. In particular, mistakes may directly or indirectly derive from daily routine processes. In addition, consequences may result from the broader pharmaceutical and technological treatment options, which frequently involve multidimensional aspects. The increasing complexity of pharmaceutical and technological properties must be monitored and taken into account. Besides the presence of various disciplines involved, the provision of 24-hour care requires multiple handovers of significant information each day. Immediate expert action that is well coordinated is just as important as a professional handling of medicines limitations. Intensivists are increasingly facing professional quality management within the ICU (Intensive Care Unit). This article depicts a practical and effective approach to this complex topic and describes external evaluation of critical care according to peer reviewing processes, which have been successfully implemented in Germany and are likely to gain in significance.

Analgosedierung – Umsetzung der S2e–Leitlinien dient der Prozessoptimierung

The S2e Guidelines for sedation practice of the German Society for Anaesthesiology and Intensive Care recommend a clear prior definition of depth of sedation to be achieved in a given case, monitoring of depth of sedation by means of scoring systems, appropriate selection of analgesics and sedatives and the use of patient-oriented treatment regimens. These measures not only reduce significantly length of artificial respiration, length of time spent on the intensive care unit and overall length of stay in the hospital but also the frequency of complications. Therefore, implementation of the Guidelines will result in significant reductions in costs in a given case. This is a decisive economic benefit for any hospital working under the restraints of the DRG system.

Ökonomie, Qualitätsmanagement und Patientendatenbankmanagementsysteme (PDMS)

Externe Qualitatssicherung, wie sie in Deutschland mit dem Kerndatensatz Intensivmedizin moglich ist, erlaubt ein Benchmarking der eigenen Station mit der Gesamtheit der Teilnehmer (Martin et al. 2004). Die Umsetzung eines gefundenen Verbesserungspotenzials muss jedoch immer uber ein internes Qualitatsmanagement durchgefuhrt werden. Ziel eines Qualitatsmanagements ist es, die Struktur und die Prozesse so zu organisieren, dass ein optimales Ergebnis entsteht.

Ökonomie und Qualitätsmanagement

Externe Qualitatssicherung, wie sie in Deutschland mit dem Kerndatensatz Intensivmedizin moglich ist, erlaubt ein Benchmarking der eigenen Station mit der Gesamtheit der Teilnehmer [1]. Die Umsetzung eines gefundenen Verbesserungspotenzials muss jedoch immer uber ein internes Qualitatsmanagement durchgefuhrt werden. Ziel eines Qualitatsmanagements ist es, die Struktur und die Prozesse so zu organisieren, dass ein optimales Ergebnis entsteht.

Prävention, Diagnose, Therapie und Nachsorge der Sepsis@@@Prevention, diagnosis, treatment, and follow-up care of sepsis: Erste Revision der S2k-Leitlinien der Deutschen Sepsis-Gesellschaft e.V. (DSG) und der Deutschen Interdisziplinären Vereinigung für Intensiv- und Notfallmedizin (DIVI)@@@First revision of the S2k Guidelines of the German Sepsis Society (DSG) and the German Interdisciplinary Association for Intensive and Emergency Care Medicine (DIVI)

(Orientiert an der Definition der Agency for Health Care Policy and Research fur die „Clinical Practice Guidelines“ der USA): „Leitlinien sind systematisch entwickelte Darstellungen und Empfehlungen mit dem Zweck, Arzte und Patienten bei der Entscheidung uber angemessene Masnahmen der Krankenversorgung (Pravention, Diagnostik, Therapie und Nachsorge) unter spezifischen medizinischen Umstanden zu unterstutzen.“ Leitlinien geben den Stand des Wissens (Ergebnisse von kontrollierten klinischen Studien und Wissen von Experten) uber effektive und angemessene Krankenversorgung zum Zeitpunkt der „Drucklegung“ wieder. In Anbetracht der unausbleiblichen Fortschritte wissenschaftlicher Erkenntnisse und der Technik mussen periodische Uberarbeitungen, Erneuerungen und Korrekturen unternommen werden. Die Empfehlungen der Leitlinien konnen nicht unter allen Umstanden angemessen genutzt werden. Die Entscheidung daruber, ob einer bestimmten Empfehlung gefolgt werden soll, muss vom Arzt unter Berucksichtigung der beim individuellen Patienten vorliegenden Gegebenheiten und der verfugbaren Ressourcen getroffen werden.