Martin Grett

Verfügbarkeit von Patientenverfügungen in einer interdisziplinären Notaufnahme

INTRODUCTION Despite an increasing attention to living wills, the effects of such living wills on patient care in the emergency departments remains unknown. MATERIAL AND METHODS All patients who were admitted to our emergency department between September 24th, 2014 and November 23th, 2014 were asked, whether they have signed living wills previously and if so, whether they have it on hand at admission. RESULTS 496 patients (229 men (46.2 %), 267 women (53.8 %)) with a mean age of 64.9 ± 18.8 years were included in this survey. 138 patients (27.8 %) had a living will but only 16 patients (3.2 %) had it on hand.Altogether, the existence of living wills increased with an increasing patient`s age; only 5 of 117 patients aged 50 years old or younger (4,3 %) had a living will, but 133 of 379 patients older than 50 years (35,1 %). DISCUSSION AND CONCLUSION Despite an obviously broad acceptance of living wills especially in the elderly population, there are hardly any consequences on the daily patient care in an emergency department by now, as hardly any patient has hers or his living will on hand at admission. We therefore see the need for further educational work to guarantee that living wills get adequate priority in patient care at emergency departments.

Stellenwert der Patientenverfügung in der Postreanimationsbehandlung

Background There is hardly any evidence about the influence of living wills on acute life-threatening disease like out-of-hospital cardiac-arrest (OHCA). We therefore initiated this study to quantify the percentage of victims of OHCA whos living wills are available during post-resuscitation care. Methods All victims of OHCA who were admitted to our hospital between January 1st 2008 and July 31th 2016 were identified by analysis of our central admission register. Data from individual patients were collected from the patients health records and anonymously stored on a central database. Results Altogether, there were 343 victims of OHCA admitted to our hospital between January 1st 2008 and July 31th 2016, including 16 patients (4.7 %) with living wills and 18 patients (5.2 %) with legal health care proxy. Survival rates were 31.2 % in patients with living wills, 27.8 % in patients with legal health care proxy and 33.3 % in patients without such a document. Conclusion In this study, the percentage of victims of OHCA with available living wills during post-resuscitation care was low. The presentation of living wills or legal health care proxies during post-resuscitation care of victims from OHCA was not equivalent to the patient`s death. Most often, discussion with relatives led to the decision to withdraw further therapy.

Erweiterung einer venoarteriellen (VA) ECMO auf eine venovenoarterielle (VVA) ECMO bei schwerem Harlekinsyndrom

ZusammenfassungEs wird über den Fall einer 34-jährigen Patientin berichtet, die nach außerklinischer Reanimation bei therapierefraktärem, kardiogenem Schock im Rahmen einer Myokarditis zunächst mit einer venoarteriellen (VA) extrakorporalen Membranoxygenierung (ECMO) stabilisiert wird. Im Verlauf entwickelt die Patientin bei schwerem Lungenversagen die typischen Befunde des sogenannten Harlekinsyndroms mit unzureichender Sauerstoffversorgung der oberen Körperhälfte. Als schnelle und effektive Lösung findet zur Verbesserung des Sauerstoffangebots von Lungen, Herz und Kopf die Erweiterung auf eine venovenoarterielle (VVA) ECMO statt. Nach Besserung der Symptomatik und weiterer Stabilisierung wird die Patientin komplikationslos in ein kardiochirurgisches Zentrum verlegt.AbstractWe report the case of a 34-year-old female patients admitted to our department of cardiology after out of hospital cardiac arrest. Due to severe therapy resistant cardiogenic shock, a peripheral veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) was implanted. With the occurrence of severe acute respiratory distress syndrome (ARDS) the patient developed the typical symptoms of the so-called harlequin syndrome with insufficient oxygenation of the upper body. The ECMO was converted to veno-veno-arterial (VVA) ECMO for rapid and effective improvement of the pulmonary, coronary and cerebral oxygen supply. After improvement of the symptoms and further stabilization the patient could be transferred to a cardiac surgery clinic without complications.

Organspende bei einer 50‑jährigen Patientin mit Trisomie 21

Aktuell stehen bundesweit mehr als 10.000 Patienten auf der Warteliste für ein Spenderorgan. Lässt man die Lebendspenden unberücksichtigt, so wurden zwischen dem 01.01.2017 und dem 31.05.2017 nur 677 Organe gespendet [1]. Somit besteht auch bei im Vergleich zum Vorjahr steigenden Zahlen an Organspendern (2015: 242, 2016: 209, bis Mitte 2017: 212) [1] weiterhin ein deutlicher Organmangel. Es ist daher eine wichtige ärztliche Aufgabe, potenzielle Organspender zu detektieren. Bei den umfangreichen juristischen und medizinischen Maßnahmen erfolgt eine Unterstützung durch die DSO (Deutsche Stiftung Organtransplantation). Auch Patientenmit Vorerkrankungen sollten nicht ohne Rücksprache als nicht geeignet klassifiziert werden. Die Trisomie 21 ist eine Erberkrankung,welche indenmeistenFällendurch eine freie Trisomie 21 entsteht. In selteneren Fällen entsteht sie durch Translokation,Mosaik-Trisomie oder sehr selten durch eine partielle Trisomie. Die Inzidenz der Erkrankung liegt in Abhängigkeit desAlters derMutter inDeutschland bei 1:800 bis 1:500 Geburten. Mit zunehmendem Alter der Mutter nimmt auch die Inzidenz zu [2]. Bei der Trisomie 21 treten gehäuft Organfehlbildungen auf. Hierzu zählen in erster Linie Herzfehler, vorwiegend Atriumseptumdefekte (ASD) oder atrioventrikuläre Septumdefekte (AVSD) bei 40–60% der betroffenen. Ebenfalls kommt es gehäuft zur Fallot-Tetralogie. Fallvorstellung

Using vascular closure devices following out-of-hospital cardiac arrest?

Objectives and Background: Despite a generally broad use of vascular closure devices (VCDs), it remains unclear whether they can also be used in victims from out-of-hospital cardiac arrest (OHCA) treated with mild therapeutic hypothermia (MTH). Methods: All victims from OHCA who received immediate coronary angiography after OHCA between January 1st 2008 and December 31st 2013 were included in this study. The operator decided to either use a VCD (Angio-Seal™) or manual compression for femoral artery puncture. The decision to induce MTH was based on the clinical circumstances. Results: 76 patients were included in this study, 46 (60.5%) men and 30 (39.5%) women with a mean age of 64.2 ± 12.8 years. VCDs were used in 26 patients (34.2%), and 48 patients (63.2%) were treated with MTH. While there were significantly more overall vascular complications in the group of patients treated with MTH (12.5% versus 0.0%; p=0.05), vascular complications were similar between patients with VCD or manual compression, regardless of whether or not they were treated with MTH. Conclusion: In our study, the overall rate of vascular complications related to coronary angiography was higher in patients treated with mild therapeutic hypothermia, but was not affected by the application of a vascular closure device. Therefore, our data suggest that the use of VCDs in victims from OHCA might be feasible and safe in patients treated with MTH as well, at least if the decision to use them is individually carefully determined.

Cardiac arrest teams and time of day: effects on surviving in-hospital resuscitation

Objectives Little is known about the factors that influence survival following in-hospital resuscitation, but previous investigations have suggested that in-hospital resuscitations outside of regular working hours are associated with worse survival rates. Material and methods In-hospital cardiac arrest teams at our hospital were instructed to complete a questionnaire following every emergency call between July 2011 and June 2013. Data on all resuscitation attempts were collected and analyzed. Results A total of 65 in-hospital resuscitations were recorded in 42 males (64.6%) and 23 females (35.4%) (mean age 72.0±14.3 years). A total of 54 (83.1%) cardiac arrests were witnessed; seven (10.8%) showed a shockable rhythm at the time of the first ECG. Resuscitation attempts lasted 29.3±41.3 minutes, and 4.1±3.1 mg epinephrine was given. Return of spontaneous circulation could be achieved in 38 patients (58.5%); 29 (44.6%) survived the first day, 23 (35.4%) the seventh day, and 15 patients (23.1%) were discharged alive. Significantly more in-hospital resuscitations were obtained for those performed during non-regular working hours (P<0.001), with higher neuron-specific enolase levels at 72 hours after resuscitation during nonregular working hours (P=0.04). Patients who were discharged alive were significantly younger (P=0.01), presented more often with an initial shockable rhythm (P=0.04), and had a shorter duration of resuscitation (P<0.001) with the need of a lower dose of epinephrine (P<0.001). Discussion Survival rates following in-hospital resuscitation were poor at any time, but appear to depend less on time-dependent effects of the quality of resuscitation and more on time-dependent effects of recognition of cardiac arrests.